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RC920  .L97  1918      A  treatise  of  cystos    H^^^^^^^^^M 

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1    lIBRASfES    1 


HEALTH 


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TREATISE  ON 
CYSTOSCOPY  AND  URETHROSCOPY 


WORKS   BY   THE   SAxME   AUTHOR 

TllAITE  DE  LA  BLENNORRAGIE  ET  CE  SES  COMPLICATIONS. 

Second  edition,  revised  and  enlarged.  One  large  volume,  Svo.,  containing 
620  pages,  with  215  figures  in  the  text  and  3  colored  plates.  .1-2  Francs 
(Crowned  by  the  Academy  of  Medicine,  Ricord  Prize,  191.3.) 

Exploration  de  l  'Appareil  urinaire. 

Second  edition,  revised  and  enlarged.     One  volume  of  GIO  pages,  with 

226  figures  in  the  text  and  6  colored  plates 20  Francs 

(Crowned  by  the  Academy  of  Medicine  of  Paris,  Laborie  Prize,  1907.) 

La  Separation  de  l 'Urine  des  ueux  reins. 

One  volume,  Svo.,  with  55  figures  in  the  text 6  Fiancs 


A  TKI]ATISI] 

ON 

CVXTOSCOl'Y  AND  UliKTHliOSCOl'V 


f 


BY 

mi.  GEORGES  LUYS 

FOKMKll    IXTKKXE,    HOSPITALS    OF    PARIS;    FOr>.JIEK,    ASSj^AXT    IX    THE    Df:PAKTMKXT    OF    URINARY 
DISEASES    AT    THE   LARIBOISIERE    IICaPITAL ;    LAUREATE    OF    THE 
FACULTY   OF   THE  ACADEMY   OF   MEDICINE.       . 


TRANSLATED  AND  EDITED  WITH  ADDITIONS 

BY 

ABR.  L.  AVOLBARST,  M.D., 

NEW  YORK 

CYSTOSCOPIST,  BETH  ISRAEL  HOSPITAL;   CONSULTING  UROLOGIST,   CENTRAL  ISLIP  AND   MANHATTAN 

STATE  HOSPITALS  ;    GENITO-URINARY  SURGEON,  WEST   SIDE  GERMAN  DISPENSARY  AND 

HOSPITAL  ;    AUTHOR  OF   *  '  GONORRHEA  IN   THE   MALE, ' '   ETC. 


rVITH  217  FIGURES  IN  THE  TEXT  AND  24  CEEOMOTTrOGI^APniC  PLATES  OUT- 
SIDE THE  TEXT,  INCLUDING  76  DRAWINGS  FPOM  ORIGINAL  WATER  COLORS. 


ST.  LOUIS 
C.  A\  MOSBY  COMPANY 

1918 


Copyright,  1918,   By  C.   V.  Mosby  Company 


Press  oi 

C.  V.  Mosby  Company 

Sf.  Louis 


PREFACE 


The  iiii])()rtaiu'('  of  ui-t'lJii-<-il  ;iih1  vesical  endoscopy  is  universally 
recognized.  Physicians  and  surgeons  are  in  constant  need  of  the  light 
shed  by  this  science,  which  is  one  of  the  principal  reasons  for  the 
existence  of  the  modern  urologist.  But  in  order  to  apply  the  art  skil- 
fully and  thereby  derive  all  the  advantages  it  is  able  to  offer,  it  is 
necessary  to  attain  considerable  practice  and  skill  in  urethroscopy 
and  cystoscopy. 

Tlianks  to  the  jDerfection  of  modern  instruments,  it  is  easy  to 
obtain  clear  and  distinct  pictures;  on  the  other  hand,  it  is  often  dif- 
ficult to  interpret  the  image  which  is  presented,  at  first  sight.  For 
tliat  reason,  it  is  necessary  to  acquire  considerable  familiarity  in  j^rac- 
tical  endoscopy,  in  order  to  attain  that  indispensable  experience  which 
gives  one  a  mastery  of  the  subject  and  the  ability  to  make  a  correct 
diagnosis. 

This  work  is  the  result  of  fifteen  years  of  practical  endoscoi^y. 
Its  object  is  to  present  to  the  medical  profession  the  procedures  and 
methods  which  have  been  so  well  perfected  as  to  enable  us  to  deter- 
mine the  condition  of  the  urethral  and  the  bladder  mucosa,  and  also 
of  the  ureters,  pelves  and  kidneys.  Its  object  is  to  meet  the  needs,  not 
only  of  students,  who  must  be  guided  gently  step  by  step  into  this 
wonderful  science,  but  also  of  those  who,  though  quite  familiar  with 
the  practice  of  cystoscop}"  and  urethroscopy,  are  not  acquainted  with 
all  of  its  useful  applications.  Undoubtedly  many  urologists  are  thor- 
oughly acquainted  with  the  ordinary  urethroscopic  an^l  cystoscopic 
technic;  nevertheless,  there  are  but  few  who  full>'  realize  all  the  ad- 
vantages that  can  be  derived  from  the  most  recent  progress  in  urothros- 
cop3^  and  cystoscopy. 

It  is  the  purpose  of  this  work  to  illustrate  and  i)oi)ularize  the 
science  of  direct  vision  cystoscoi)y  and  the  marvelous  ai)plications 
which  it  renders  possible.  The  treatment  of  i)rostatic  hypertr()i)liy 
endourethrally,  the  endovesical  treatment  of  l)ladder  tumors,  the  re- 
moval of  foreign  bodies  from  the  bladder,  and  biopsy  of  the  liladder, 
are  just  so  many  ccuupiests,  as  yet  too  little  known,  and  Avhicli  it  is 
well  to  make  known  to  the  medical  world. 

Since  the  onset  of  the  present  AVorld  AVar,  sclent ilic  activity  has 

9 


10  PREFACE 

diminished  everywhere,  owing  to  tlie  more  serious  duties  with  which 
scientific  men  find  themselves  preoccupied. 

Doctor  Wolbarst,  of  New  York,  who  has  undertaken  to  translate 
my  work  into  English,  and  whom  I  have  given  sole  authority,  with 
the  greatest  pleasure,  is  perfectly  qualified  to  do  the  subject  justice: 
for  the  large  experience  which  this  well-known  urologist  has  acquired 
in  his  specialty  has  fitted  him  perhaps  better  than  anyone  else  to 
understand  and  interpret  my  work. 

It  has  been  a  great  satisfaction  to  me  to  know  that  in  the  work 
that  he  has  done  he  has  almost  always  reached  the  same  conclusions 
and  found  the  same  therapeutic  indications  as  I  have  in  my  own 
practice. 

I  am  glad  to  state  that  this  important  translation  which  he  has 
undertaken  this  year,  has  been  brought  up  to  date,  and  that  the  reader 
will  find  all  the  information  necessary,  not  only  as  to  the  technic  of 
cystoscopy  and  urethroscopy,  but  also  in  the  therapeutic  applications 
of  these  instruments. 

The  book  consists  of  six  chapters.  Urethral  and  vesical  endos- 
copy are  first  studied  historically  and  in  a  general  way.  This  is  fol- 
lowed by  a  chapter  on  urethroscopy  proper,  and  another  on  the  use  of 
urethroscopy  in  catheterization  of  the  ejaculatorj^  ducts  and  in  the 
endoscopic  treatment  of  prostatic  hypertrophy.  The  remainder  of  the 
work,  that  is,  its  major  portion,  is  devoted  to  the  stud}^  of  cystoscopy. 

Cystoscopy  in  general,  jDrismatic  (indirect)  cystoscopy,  and  direct 
vision  cystoscopy  are  considered,  not  so  much  from  the  instrumental 
standpoint,  which  would  only  constitute  a  tedious  recital,  as  from  the 
point  of  view  of  the  practical  results  obtained  with  the  use  of  these 
instruments.  The  chapter  on  the  cystoscopic  appearance  of  the  nor- 
mal and  pathologic  bladder  has  been  treated  with  special  detail  be- 
cause of  its  very  great  importance.  Direct  vision  c^^stoscopy  is  de- 
scribed in  all  its  details  in  the  succeeding  chapter. 

Further  on,  catheterization  of  the  ureter  w^ith  its  technic,  its  indi- 
cations, difficulties,  and  accidents  is  taken  up  fully;  likewise  the  oppor- 
tunities offered  by  ureteral  catheterization,  such  as  the  search  for 
ureteral  calculus,  the  treatment  of  renal  colic,  the  exploration  of  the 
renal  pelvis,  the  treatment  of  pyelitis  by  jDclvic  lavage,  also  radiog- 
raphy and  pyelography. 

The  next  chapter  considers  the  practical  applications  of  cystos- 
copy^; that  is,  the  endovesical  treatment  of  bladder  tumors  by  gal- 
vanocauterization,  the  cold  or  hot  snare,  electrocoagulation,  electrol- 
ysis and  radium. 


PREFACE  11 

The  hist  cliaiotcr  is  devoted  to  tlie  treatment  of  foreign  bodies  in 
llie  l)laddor  and  of  the  cystitos.  Tliere  is  also  a  consideration  of  the 
instrumental  exploration  of  the  lower  end  of  the  ureter  and  of  vesical 
biopsy. 

Particular  attention  has  been  given  to  the  illustrations.  The  247 
illustrations  in  black  together  with  the  24  colored  plates  appeal  directly 
to  the  eye  of  the  reader.  In  the  study  of  endoscopy  nothing  is  so  im- 
l)ortant  as  to  establish  a  clear,  reliable  picture  in  the  mind's  eye,  so 
that  the  reader  may  remember  it  and  be  able  to  make  a  correct  diag- 
nosis in  cases  occurring  in  his  practice. 

AVith  pleasure,  I  express  to  the  publishers,  Messrs.  0.  Doin  &  Son, 
gratitude  for  the  care  they  have  exercised  in  the  publication  of  this 
work;  I  also  thank  M.  Dupret,  draughtsman,  for  the  consummate  art, 
as  well  as  the  untiring  patience,  which  he  has  been  so  good  as  to  exhibit 
in  the  detailed  endoscopic  work  which  Avas  entrusted  to  him. 

Georges  Luys 

Paris,  France. 

January,  1918 


TRANSLATOR'S  PREFACE 


Tliis  Irniislation  of  Tjiiys'  woi-k  on  "Cyslosc()i)y  and  Uretliros- 
copy"  was  undertaken  with  a  twofold  purpose  in  view:  First,  to 
l)rini;'  to  American  and  other  English-speaking  urologists  the  message 
which  Luys'  book  bears;  and  secondly,  to  express  in  concrete  form 
the  love  and  affection  which  the  translator  feels  for  France. 

This  work  was  undertaken,  in  the  first  weeks  of  the  great  "World 
War, — weeks  in  which  the  fate  of  glorious  France  and  the  rest  of  the 
civilized  world  hung  in  the  balance.  And  when,  as  if  by  a  miracle, 
Paris  was  saved  and  the  invader's  progress  arrested  at  her  very 
gates,  and  all  lovers  of  France  breathed  once  more,  it  seemed  to  be  a 
sacred  duty  and  a  pleasure,  as  well,  to  bring  this  fine  book  by  one  of 
her  greatest  urologists  within  easy  reach  of  his  confreres  in  America. 

Lu3^s'  work  is  frankly  a  plea  in  behalf  of  direct  vision  cystoscopy 
and  urethroscop3^  In  America  this  method  has  not  received  the  wide- 
spread and  almost  universal  welcome  that  has  been  accorded  the  indi- 
rect method.  Nevertheless,  whatever  the  reason  may  be,  it  is  felt  that 
American  urologists  will  w^elcome  this  thorough  exposition  of  the  direct 
method,  so  that  they  may  at  least  compare  it  with  the  method  with 
which  they  are  more  familiar. 

Several  features  stand  out  strikingly  in  contrast  with  usual  works 
of  this  kind:  First,  the  extensive  and  illuminating  historical  data, 
showing  the  origin  and  development  of  cystoscopy  and  urethroscopy; 
secondly,  the  discussion  of  topics  that  are  not  strictly  urologic,  but 
closely  affiliated,  such  as  the  sections  on  uterine  cancer  and  pregnancy. 

The  translator  has  striven  faithfully  to  transpose  the  author's 
lyric  French  into  plain  English, — frankly,  a  difficult  task.  There  is 
always  a  fear  of  failure  to  express  the  author's  exact  meaning;  but 
the  effort  has  been  made  honestly,  and  it  is  hoped,  successfully.  Xo 
attempt  has  l)iH'n  nuuh'  to  alter  the  tyineal  French  character  of  the 
work.  Whatever  additions  or  amendments  have  been  made,  have 
lieen  inserted  either  for  the  purpose  of  bringing  the  subject  matter  uj) 
to  the  minute,  as  it  were,  or  in  order  to  make  the  subject  more  practical 
for  American  readers. 

I  would  take  advantage  of  this  oj)portunity  to  thank  Dr.  William 
E.  Ciould,  and  my  staff  assistant.  Dr.  S.  Steiner,  for  valuable  assistanc(^ 

13 


14  translator's  preface 

rendered  in  the  translation;  also  Dr.  William  F,  Braascli,  of  the  Mayo 
Clinic,  for  his  fine  little  article  on  "Direct  Cystoscopy;"  and  lastl}'^, 
but  by  no  means  least,  The  C.  V.  Mosby  Company,  that  has  undertaken 
the  publication  of  the  translation  in  this  inauspicious  time  of  high 
cost  of  production,  simply,  to  use  its  own  words,  as  its  ' '  contribution  to 
France."  It  is  a  jDleasure,  as  well  as  a  privilege,  to  subscribe  to  that 
sentiment. 

Abr,  L.  Wolbarst 

New  York  City 
May,  1918. 


CONTENTS 


PAOK 

Chapter  I. — History  ok  Ukk/i'iikai,  a.\d  Vksical  Endoscopy 25 

History  of  Eiidoscoj^y 25 

History  of  Urethroscopy       27 

Urethroscopes   with   External   Ilhimination 27 

Urethroscopes    with    Internal   Illumination 36 

Luys'   Urethroscope 43 

Urethroscopes  for  the  Posterior  Uretlira 47 

History  of   Cystoscopy 54 

History  of  Direct  Vision  Cystoscopy 50 

Chapter  II. — Urethroscopy       65 

Technic  of  Urethroscopy 70 

Contraindications  to  Urethroscopy 81 

Urethroscopy  of  the  Normal  Urethra 82 

Urethroscopy  of  the  Pathologic  Urethra 88 

Urethroscopy  in  the  Female 110 

Chapter  III. — Practical  Application  of  Urethroscopy 115 

Catheterization   of   the   Ejaculatory  Ducts 115 

Eiidourethral  Treatment  of  Prostatic  Hypertrophy 135 

Chapter   IV. — Cystoscopy 139 

.Anatomic   Considerations 147 

Ureteral  Meatotomy 150 

Ureteral  Ejaculation 158 

Errors  in  Cystoscopy 162 

Dangers  of  Cystoscopy     : 105 

Vesical  Phantoms 167 

Chai'ter  V. — PmsMATic    (iKDUtEcr   Vision)    Cystoscopy IfiS 

Nitze  's  Cystoscope 168 

Modification  of  Nitze 's  Cystoscope 172 

Technic  of  Indirect  Vision  Cystoscopy ISl 

Diflficulties  of  Indirect  Vision  Cystoscopy 189 

Normal  Bladder  as  Viewed  through  the  IiKliicd    X'isimi  Cystoscojie 198 

Pathologic  Bladder  as  Viewed  tlirougli  tlie   liidiiect  \'isi(iu  ('yst()S(M)|H' 199 

Acute   Cystitis 199 

Chronic  Cystitis 200 

Cystoscopy  in  Tumors  of  the  BhuliiiT 205 

Cystoscopy  in  Anomalies  of  the  Biaddci- 20() 

Cystoscopy  in  Cancer  of  the   Uterus 207 

Cj'stoscopy  in  the  Cancerous  Biaddci- 20S 

15 


16  CONTENTS 

PAGE 

Chapter   VI. — Direct   Vision   Cystoscopy 218 

Conditions  Necessary  for  Direct  Vision  Cystoscopy     . 218 

Description  of  Luys'  Direct  Vision  Cystoseope 225 

Teclmic  of  Direct  Vision  Cystoscoiay 229 

Advantages  of  Direct  Vision  Cystoscopy  in  Examination  of  the  Bladder 234 

Objections  to  Direct  Vision  Cystoscopy 242 

Comparative  Eole  of  Indirect  and  Direct  Vision  Cystoscopy     .     .     . 243 

Direct  Vision  Cystoscopy  During  Pregnancy 248 

Chapter  VII. — Catheterization  of  the  Ureters 254 

Ureteral  Catheterization  with  the  Indirect  Vision  Cystoseope 254 

Technic  of  Ureteral  Catheterization  with  the  Indirect  Cystoseope 263 

Ureteral  Catheterization  with  the  Direct  Vision  Cystoseope 267 

Technic  of  Ureteral  Catheterization  with  Luys'  Cystoseope 269 

Choice  of  Method  in  Ureteral  Catheterization 285 

Indications  for  Direct  Cystoscopy  in  Ureteral  Catheterization 285 

Indications  for  Indirect  Cystoscopy  in  Ureteral  Catheterization 290 

Difficulties,  Accidents,  and  Errors  in  Ureteral  Catheterization 291 

Accidents  Associated  with  Ureteral  Catheterization 293 

Errors  Associated  with  Ureteral  Catheterization 298 

Ureteral  Catheterization  in   Children 306 

Chapter  VIII. — Information  Derived  through  Ureteral  Catheterization     ....  307 

Exploration  of  the  Ureter 307 

Detection  of  Ureteral  Calculi 307 

Treatment  of  Nephritic  Colic 312 

Exploration  of  the  Eenal  Pelvis 313 

Ureteral  Catheterization  in  Kidney  Function  Tests 319 

Treatment  of  Pyelitis  by  Pelvic  Lavage 320 

Ureteral  Catheterization — a  Demeure 324 

Radiography  of  the  Ureteral  Catheter 326 

Pyelography 326 

Chapter  IX. — Practical  Applications  of  Cystoscopy 329 

Treatment   of   Bladder   Tumors 329 

Endovesical  Treatment  of  Bladder  Tumors 330 

Galvanocauterization 330 

Nitzc's   Method 331 

With  the  Direct  Vision  Cystoseope 332 

Technic   of  the  Endovesical   Treatment   of  Bladder   Tumors  with   Luys'   Operating 

Cystoseope 333 

Treatment  of  Bladder  Tumors  with  the  Cold  or  Hot  Snare 342 

Electrocoagulation  of  Tumors  of  the  Bladder 347 

Endovesical  Treatment  of  Bladder  Tumors  by  Electrolysis 354 

Endovesical  Treatment  of  Bladder  Tumors  by  Radium 355 

Chapter  X. — Treatment  of  Foreign  Bodies  in  the  Bladder 357 

Actual   Foreign   Bodies 357 

Treatment  of  Vesical  Calculi 354 

Treatment    of    Cystitis 374 

Instrumental  Exploration  of  the  Inferior  Extremity  of  the  Ureter 374 

Vesical  Biopsy 37g 


ILLUSTRATIONS 


kk;.  pack 

1.   T)('s()iitu';uix 's    ur('tlni>s('()]u> • 27 

'2.    Iliir1('|(ni|i 's   iii('11ii(iscu|i(' 28 

'A.  Lc'ilci  's   paiiclcctioscopc 28 

4.  Scluitzo'.s    (lia])hotoseo]ie 29 

5.  Xyrops'  oleftrnuiotliioscopo 20 

().  Laiiy 's  iii'('tlirosc()|)o 29 

7.   Otis'   uioHnoscope ."^O 

S.  Casper's  electroscope ^'>0 

9.  Antal's  aorouretliroscope •"''1 

1  ().  Fenwick  's   aerourethroscope 32 

n.  Clar's  photophore 33 

12.  Urethroscopie    tul)e    and    its    iil)turator 33 

13.  Griinfeld's  tul)(^  witli  wimlow  and   iiiiri'or 34 

14.  Horteloup's   bivalve    speculum 34 

15.  Kollmann-Wiehe  tubes 35 

Ki.  Nitze's  urethroscope 37 

17.  Oberlaender's  urethioscope 37 

18.  Valentine's  urethroscopie  lamp 38 

19.  Valentine 's  lamp  carrier 38 

20.  Oberlaeuder-Kollmann  urethroscopie  tube 38 

21.  Valentine's   urethroscopie   outfit 39 

22.  Kollmaun's  photographic  urethroscope 39 

23.  Handle  of  Kollmann-Wiehe 'a  urethroscope,  provided  willi  an  dptic  ap[iaratus     ...  40 

24.  Wasserthal  's   aerourethroscope 40 

25.  Gordon's  endoscope 41 

2G.  Handle   and  telescope   of   Kaufmann's   uretlirosco|)e 41 

27.  Luys'  long  cystoscopie  tulie  and  its  obturator 43 

28.  Luys'  short  urethroscopie  tulie  and  its  lamp 43 

29.  Handle  of  Luys'  urethroscope 45 

.'!0.  Improved  model  of  the  handle  of  Luys'  uretludscojie 45 

31.  Profile  view  of  Luys'  urethroscope    ( complete ) 40 

32.  Illustrating  liow  the  prominence   of  tlie  veramontanum   aiK^sts   aiul   nbstrucls  tiu^  ex- 

tremity of  the  urethroscopie  tube 47 

33.  Le  Fiir's  urethroscopie  lamp 48 

34.  Le  Fiir's  uretlu'oscope 48 

'.)').  (ioldschmidt 's  j^osterior  urethioscope 48 

.">().  (ioldschmidt 's  anteiior  urethroscope 49 

37.  Buerger's   cystoui('throsco])e 50 

38.  Wossidlo's  posteiior  urethroscope     .      .    * 51 

;i9.    Kelly's    cndo.-coiiir    tulie 57 

4(1.   Mcthoil    of    liolding    Kelly's    endnscoiiic    tube 57 

41.  I'awlicU's   eiidosco|ii('    tulic    :inil    ohluratoi- 58 

42.  Ptiwlick's  endoscope   with    its   lam|i   and    ii'rigaliiig   a|i|iaiatns 58 

4.'!.  Gaireau's  endoscopic  tube  with   its  uiin<'  asiiiralor 59 

-14.   ('ulli'ii's    cysloscope GO 

17 


18  ILLUSTRATIONS 

FIG.                                                                                                                                                                          **  PAGE 

45.  Urethroscopie  examining   table    (author's  model) 71 

4G.  Rheostat  for  light  and  cautery  adapted  for  city  cun-ent 72 

47.  Rheostat  for  light  and  cautery,  using  city  current 72 

48.  Rheostat  for  light,  using  city  current 73 

49.  Light  controller 73 

50.  Pocket    battery      .     .   " 73 

51.  Sigurta's  portable  battery  for  electric  illumination 74 

52.  Wooden  cotton  carrier 74 

53.  Special   forceps   for   intraurethral   work ■ 74 

54.  Examination  of  the   anterior  urethra 75 

55.  Examination  of  the  posterior  urethra .75 

56.  Ten  cubic  centimeter  syringe .  76 

57.  Introduction  of  the  urethroscopie  tube  into  the  posterior  urethra •.  76 

58.  The  Urethroscopie  tube  having  been  introduced,  the  obturator  is  withdrawn  and  the 

handle  is  attached  to  the  collar  of  the  tube   (lamp  pointing  downward)      ...  77 

59.  In  the  examination  of  the  posterior  urethra,  the'  handle  of  the  urethroscope  is  turned 

upward,  the  lamp  also  upward 78 

60.  Intraurethral  manipulation;  drying  the  mucosa  with  cotton  swabs     .......  79 

61.  Urethroscopie  view  of  the  "prostatic  fossette" 85 

62.  Anatomic  view  of  the  "prostatic  fossette,"  comprised  Ijotween  the  posterior  margin 

of  the  verumontanum  and  the  bladder  neck 85 

63.  Normal  verumontanum,  the  orifice  of  the  prostatic  utricle  not  visible 86 

64.  Normal  verumontanum,  the  orifice  of  the  prostatic  utricle  visible 86 

65.  Normal  verumontanum,  without  a  median  prostatic  utricle ,  87 

66.  Kollmann's  pipette,  for  aspirating  the  glandular  secretions 90 

67.  Little  polypus  situated  at  the  bottom  of  a  lacuna  of  Morgagni 91 

68.  Urethroscopie  lesions  of  the  prostatic  fossette,  behind  the  verumontanum     ....  101 

69.  Glandular  lesions  of  the  anterior  surface  of  the  prostate,  seen  with  the  urethroscope     .  102 

70.  Polypus  on  the  summit  of  the  verumontanum 107 

71.  Long  eel-shaped  polypus  on  the  anterior  aspect  of  the  verumontanum     ......  107 

72.  Long  phallus-shaped  polypus  on  the  superior  aspect  of  the  verumontanum     .     .     .     .  108 

73.  Hypertrophied  verumontanum,  the  result  of  a  chronic  inflammation 110 

74.  Luys'   direct   vision   cystoscope,   female   model,   complete .  Ill 

75.  Large  pediculated  polypus  in  the  female  urethra __  112 

76.  Classic  arrangement  of  the  ejaculatory  canals 116 

77.  Verumontanum   without   any  visible   orifice 117 

78.  Ejaculatory  canals  opening  on  the  lips  of  the  prostatic  utricle 117 

79.  No  prostatic  utricle  visible;  the  ejaculatory  canals  open  on  the  lateral  walls  of  the 

verumontanum,  resembling  a  diver's  helmet 118 

80.  The  ejaculatory  canals  open  on  the  lateral  walls  of  the  verumontanum  but  at  dif- 

ferent levels lis 

81.  Urethroscopie  view  in  which  the  prostatic  utricle  is  visible 119 

82.  The  ejaculatory  canals  made  visible  only  after  incision  of  the  utricle 119 

83.  Gun-barrel  aspect  of  the  ejaculatory  canals 120 

84.  A  stylet  introduced  into   the   orifice '  of  the   ejaculatory   canals,   enters  the   seminal 

vesicles,  and  not  the  vas  deferens ■ 123 

85.  ''Vesicular  casts,"  obtained  by  massage  of  the  seminal  vesicles 123 

86.  Metallic  bougies  for  catheterization  of  the  ejaculatory  canals 130 

87.  Star-shaped  cicatrix  resulting  from  a  perforation  of  the  bladder,  due  to  an  abscess 

of  the  right  iliac  fossa I43 

88.  View  of  a  vesical  perforation  of  an  adjacent  abscess I44 

89.  The   floor   of    the   bladder '.'.'.'.  148 

90.  Normal  ureteral  orifice  projecting  like  a  papilla I5I 


TTJJJSTRATTONS  1^ 

PIG.  PACK 

ill.    XiiiiiNil    iii'clci'il    iiiilii-i'   ill   llir  sliii|i('  III'  ;iii   iilili(|ii('  clcCt 151 

ill'.    L:ii-f,    (i[i(Mi    inclcrnl    orilirc 151 

il.'l.    rictt'i'iil  (uKicc  sliiipcil   liUc  llu'  licak  of  v.  claiiniicl  tc      .           151 

!t4.   Uiclcral  orifice  IciigtlKMicd   into  ;i  sliar|i   line 151 

!t5.  NiiTiow  ui'Ptoral  orifice  with  thiclveiicil   lips,  iiulii-iitixi'  nt'  :i   inilij   pvclilis     ....  151 

9(5.  Arch-sluipcd  orifice  indicative  of  a  ureteral  dilatation 151 

07.  Golf-hole-shaped  lU'eteral  orifice,  indicatin<i'  a  destruction  n\'  llic  l;idiicy,  as  ohscrved 

in  renal  calculus  and  tuberculosis 151 

its.    Retraction  of  tlie  uretei-al  oiifice,  tlie  result  (if  an  iiiliaiiiiiiat idii  uT  tlic  uietei'      .     .      .  15-1 

ilii.    I'loJajise  iii'  tiic  iiiwcr  c.xl  iciiiity  (if  the  li^lit  ureter 155 

liHI.    I'lolapse   of    llie    iiicler,    witli    ureleial    i-aleiijiis,    ami    eiipped    liy    a    secundaiy    vesical 

calculus 15t! 

lol.  Auonuily    of   the   ureteral   orifices 157 

10:2.  Anomaly   of   the   ureteral   orifices 157 

103.  Ejaculation  of  thick  pus,  like  a  wliirlpool,  from  a  ureteral  orifice 161 

104-.  Ejaculation  of  pus  from  a  ureteral  orifice  as  from  a  tidic  of  jiaint 162 

105.  Bladder  phantom 166 

10().  Nitze's  cystoscope 169 

107.  Sectional  view  of  Nitze's  cystoscope 169 

108.  Optical    system    of    Nitze's    cystoscope 169 

10i».  C}'stoscoj)e  lamp  and  its  mounting 170 

110.  Ordinary  attachment  of  the  indirect  cystoscope 171 

111.  E.  Frank's  improved  attachment  for  the  indirect  cystoscope 171 

112.  Course  of  the  light  rays  in  the  Nitze-Frank  cystoscope 172 

11.1.  Cystoscopic   image   in  the   early   cystoscopes    (inverted) 173 

114.  Cystoscopic  image  corrected  in  Frank's  new  cystoscope 173 

115.  Course  of  the  light  rays  in  a  cystoscope,  with  Ringleb's  system 173 

116.  Amici's  prism,  in  the  form  of  a  housetop 174 

117.  Brenner's  cystoscope 174 

118.  Automatic  valve,  in  irrigating  cystoscopes 177 

119.  Schlagintweit's  cystoscope 178 

120.  Kutner  's  demonstration  cystoscope 178 

121.  Sectional  view   of  Kutner 's   cystoscope 178 

122.  Jacoby's    corrective    mounting .^ 179 

123.  Kollmann's  photographic  cystoscope 180 

124.  Formaldehyde  sterilizer 181 

125.  Indirect   (prismatic)   cystoscopy;   position  of  operator  and   jiatient 183 

126.  Application  of  the  indirect  cystoscope 184 

127.  First  step  in  the  introduction  of  the  indirect  cystoscope 185 

128.  Second  step  in  the  introduction  of  the  indirect  cystoscope 185 

129.  Third  step  in  the  introduction  of  the  indirect  cystoscope 187 

130.  Fourth  step  in  the  introduction  of  the  indirect  cystosco|)e 187 

131.  Faulty   introduction    of   the   cystoscope 192 

132.  Large  visual  field  of  Nitze's  cystoscope 194 

133.  Schematic  representation  of  the  reflection  of  an  iiHai;e  in  a   jilane  mirror     ....  195 

134.  Schematic   representation   of   Nitze's    systojn 195 

135.  Same  as  Fig.  134 195 

136.  Same  as  Fig.  134 ■ 196 

137.  Same  as  Fig.  134 196 

138.  Genupeetoral  position  adojited  by  Kelly  for  endoscopic  examination  in  the  male     .     .  220 

139.  Metliod  of  introduction  of  Kelly's  endoscopic  tube  in  the  male 220 

140.  Position  of  female  organs  in  the  inclined  position 221 

141.  Position  of  female  organs  in   the  genujiectoral   position 221 


20  ILLUSTEATIOlSrS 

FIG.  PAGE 

142.  First  stei^  in  the  examination  of  the  blaflcler  in  the  genupectoral  position  in  tlie  male  222 

143.  Local  treatment  of  cystitis  in  the  male,  in  the  genupectoral  position 223 

144.  Water   horn    (faucet) 224 

145.  Luys'  female  cystoseope,  with  its  straight  oljturator 224 

146.  Luys'  male  cystoseope,  with  its  ell)()we(l  obturator 224 

147.  Handle  of  the  direct  vision  cystoseope,  with  its  movable  lens 225 

14S.  Collin's   group   of  batteries 226 

140.  Luys'  direct  vision  cystoseope  for  the  female 226 

150.  Luys'  direct  vision  cystoseope  for  the  male 227 

151.  Tampon  of  cotton  mounted  on  a  wooden  applicator 229 

152.  Table  specially  built  for  urinary   examination,  horizontal   position 229 

153.  Table  specially  built  for  examination  with  direct  vision  cystoseope     .     .     .     .     .     .  230 

154.  Examination  of  the  bladder  with  the  direct  vision  cystoseope 231 

155.  Examination  of  the  bladder 232 

156.  Assistant  elevating  the  abdominal  wall 233 

157.  Vesicovaginal  fistula 237 

158.  Determining  the  exact  position  of  the  orifice  of  a  fistula  by  means  of  direct  vision 

cystoscoijy 238 

159.  Diagram  showing  the  arrangement  of  the  ureterovesicovaginal  fistula 239 

160.  Diagrammatic  section  showing  the  aspect  of  the  bladder  in  pregnancy 248 

161.  Frozen  section  of  a  j)regnant  female 249 

162.  Aspect  of  the  bladder  in  a  frozen  section  of  a  j^iegiiant  female 250 

163.  View  of  the  bladder  and  ureteral  orifices  in  the  pregnant  female 252 

164.  Mtze's  cystoseope  for  ureteral  catheterization;  improved  model 256 

165.  Casper's  ureteral  cystoseope 256 

166.  Casper's  double  ureteral  cystoseope 256 

167.  Albarran's  simple  cystoseope 257 

168.  Albarran's  cystoseope  provided  with  its  ureteral  attachment 257 

169.  Albarran's  deflector '  .  257 

170.  Bierhoff's  modification  of  Albarran's  cystoseope 259 

171.  Freudenberg 's  cystoseope  for  catheterization  of  both  ureters 260 

172.  External   tube   of   Freudenberg 's    cystoseope 260 

173.  Optical  portion  (telescope)  of  Freudenberg 's  cystoseope 260 

174.  Irrigating  tube  of  Freudenberg's  cystoseope 261 

175.  Ureteral  catheter   guides  for   Freudenberg's   cystoseope 261 

176.  Cross    section    of    Freudenberg's    cystoseope 261 

177.  Position  of  the  cystoseope  and  the  hands  in  catheterizing  the  left  ureter     ....  263 
1  78.  Position  of  the  cystoseope  and  the  hands  in  catheterizing  the  right  ureter     ....  264 

179.  Ureteral  catheter  in  favorable  position  for  easy  entrance  into  the  ureteral  orifice     .  265 

180.  Ureteral  catheter  in  poor  position 265 

181.  The  ureteral  catheter  having  entered  the  right  ureter 265 

182.  The  ureteral  catheter  having  entered  the  left  ureter 265 

183.  Pawlick's  ureteral  catheters 268 

184.  Kelly's  ureteral   explorer 268 

185.  Finding  the  ureteral  orifices  with  Luys'  direct  vision  cystoseope 271 

186.  View   of   the   left   ureteral   orifice   magnified   by   the   lens   of    Luys'    direct    vision 

cystoseope 272 

187.  Direct  catheterization  of  the  left  ureter 273 

188.  Small   catheter   provided  with   a  metallic   stylet   for   direct   catheterization    of   the 

ureter   in   the   female 274 

189.  Ureteral  catheter  devised  especially  for  direct  catheterization  of  the  ureter     .     .     .  274 

190.  Direct  ureteral  catheterization  in  the  male 275 

191.  Enormous  distention  of  the  renal  pelvis 278 


.LCSTKATIONS 


21 


|,|,;.  PAWE 

liil!.    I'rctcr.-il    cat  licl  ri'    within    a    iiictcr 302 

l!)."..   Nit/.o's    luetoial    catlictois    will:     iloiiMi'    canals .''.OP. 

1!I4.   Wax-tii)]icil  cathotors  lioaiin^  llic  si-raldi   inaiks  dT  a  <-alculus HOS 

111.-,.    TivUMal    calruli -".OO 

I'.K).  Calculous    py()iie|)lir().sis    (cxtrnial    a.-^in'cl  j -'.Ifi 

If) 7.  Calculous  pyonephrosis 317 

Tits.  Conf.eiiitalliyclronephro.sis  rrsultiu^-  in  an  aluhiniinal  renal   lislnla 325 

iilO.  Nitzo's  operating-  cy.stnseo|u'     .     .           331 

lidO.    l)(_'striU'tioii  by  Inirninfj  of  a  bladder  tunioi    tliroii-h  the   natuial   |ia.ssages     ....  334 

'2i)\.   \'esical   papilloma;    microscopic   soctiou 338 

L.'iil!.    i'liiin's  (i]ierating  cystoscope 343 

:Jll.").  Cuitent  transformer  for  electroc(.>aL;'ul:itinn 348 

li04.  View  of  a  bladder  tumor  situated  in  median  line  nf  the  trijione 351 

-05.  8ami>  as  Fig.  204.     First  application  of  electroco;iuulation 351 

•200.   Same  as  Fig.  204.     Eight  days  after  the  application  of  el(>c1  rocnagulatiou      .     .     .  352 

'207.  Same  as  Fig.  204.     Second  application  of  electrocoagulation 352 

20S.  Same  as  Fig.  204.     Fifteen  days  after  the  application  of  electrocoagulation     .     .     .  353 

209.  Celluloid  hairpin,  after  having  lain  in  the  bladder  nine  days 359 

210.  Forceps  for  the  extraction  of  foreign  bodies  through  the  direct  vision  cystoscope     .  o59 

211.  Fragment  of  a  Pezzer  catheter,  broken  off  in  the  bladder 360 

2]  2.  View  of  the  bladder  mucosa  in  bullous  cystitis 362 

21.'".   Thti'e  strands  of  silk  thread  the  ends  of  which,  project    into  the  bladder     ....  363 

214.  Three  additional  strands  of  thread,  with  a  knot  projecting  into  the  bladder     .     .     .  363 

215.  View  of  a  phosphatic  calculus  seen  through  Luys'  direct  vision  cystoscope     .     .     .  .365 

216.  Extraction  of  a  phosphatic  calculus  through  Luys'  direct  vision  cystoscope     .     .     .  367 

217.  Silver   nitrate   stick   for   endovesical   cauterization 373 


COLOR  PLATES 


l>LATK  PAGE 

I.  The  verumoutiimim 5L 

II.  Eel-shaped  and  phallus-shaped  polvpi  on  tlic  vcnmioiitaiiimi 66 

III.  Glandular  lesions  of  the  uictliia  and  prostate 89 

IV.  Pathologic  lesions  on  the  verumontanum   and  prostate 92 

V.  Lesions  of  the  verumontanum;  also  showing  the  ejaculatory  ducts 104 

VI.  Prostatic  cavern  in  chronic  prostatitis ;  urethroscopic  view  of  a  urethral  stricture  122 

VII.  Endoscopic  views  of  the  anterior  urethra 132 

VIII.  Pathologic  lesions  of  the  male  urethra ;  enormous  polypus  of  the  female  urethra     .  146 

IX.  Papillomatous  tumor  of  the  bladder 160 

X.  Normal  and  pathologic  views  of  the  bladder 176 

XL  Silk  thread  in  the  bladder;   syphilis  of  the  bladder 188 

XII.  Normal  and  pathologic  views  of  the  bladder  and  ureters 202 

XIII.  Normal   ureteral   orifice;    same    in   pregnancy;    ureteral    emission;    trabeculatcd 

bladder;    urethrovesicovaginal   fistula 214 

XIV.  Chronic    cystitis;    vesical    herpes 228 

XV.  Vesical  leucoplakia;  cluonic  cystitis 240 

XVI.  Tubei'culous  ureteral  orifice  and  vesical  ulcerations 258 

XVII.  Polypi   on  the   vesical   neck 270 

XVIII.  Phosphatie  vesical  calculi;   tul)erculous  vesical  ulcerations 284 

XrX.  Cancerous  tumors  of  the  bladder 300 

XX.  Inflammation  and  localized  abscess  of  the  vesical  neck 310 

XXI.  Bullous   edema   of  the   vesical   fundus 322 

XXIL  Tumor  of  the  roof  of  the  vesical  neck ;  vesical  fistula 336 

XXIII.  Edema  of   the  ureteral  orifice 344 

XXIV.  Vesical  tumor;  vesical  cancer;  bullous  edema;  purulent  ureteral  ejaculation     .     .  358 


CVSTOSCOI^Y  AND  Uin:rHliM)SC()PV 


CHAPTER  I 
liiSTUliY  OF  UliETHRAL  AND  M^:hICAL  ENDOSCOPY 

HISTORY  OF  ENDOSCOPY 

Ever  since  ancient  times,  physicians  liave  made  efforts  to  inspect 
the  natural  ca^T.ties  of  the  body  mth  special  instruments.  Even 
aniono-  the  ancient  Hebrews^  the  use  of  the  vaginal  speculum  was 
alread}'  known;  and  in  the  surgical  arsenal  which  was  discovered  in 
the  excavations  at  Pompeii,  instruments  designed  for  the  exploration 
of  the  rectum  were  found.  Naturally,  instrumental  examination  could 
I)e  made  only  of  the  large  body  cavities  which  are  easy  of  access,  such  as 
the  mouth,  vagina,  and  rectum.  Efforts  to  penetrate  a  ca^^ty  A\itli  a 
hmien  as  narrow  as  that  of  the  urethra  or  the  bladder,  were  in  vain,  and 
tlie  first  solutions  of  this  difficult  problem  l^egan  to  show  themselves 
only  as  we  approach  modern  times. 

Historically  considered,  it  appears  tliat  endoscopy  only  goes  as 
far  back  as  the  beginning  of  tlie  nineteenth  century,  and  it  was  Bozzini, 
of  Frankfort,  who  in  1805  was  the  first  to  attempt  the  direct  inspection 
of  the  cavities  of  the  body.  He  constructed  tubes  of  different  shapes 
and  lengths,  chiefly  for  the  study  of  the  urethra.  To  illuminate  the 
interior  of  his  tubes,  lie  ('mi)loyed  reflected  light;  but  this  form  of 
iiisti'umentation  was  certainly  too  primitive  and  defective,  and  bis 
ffuitless  efforts  wei-e  quickly  forgotten.  Similar  efforts  of  Fisher, 
of  Boston,  in  1824,  met  with  (Mpial  lack  of  success. 

Later,  in  1826,  Segalas-  presented  to  the  Academy  of  Sciences  of 
X^aris  a  urethrocystic  speculum,  designed  for  tlie  examination  of  the 
urethra  and  bladder.  This,  too,  Avas  soon  foi-uotten.  He  employed 
two  coneenti-ic  metal  tubes,  the  innei'  perniilting  a  \ie\v  of  the  blad- 
der while  the  outer  allowed  the  light  from  two  candK's  to  enter,  th'- 
light  being  i-eflected  by  a  concave  mirror. 

The  real  beginnings  of  endoscopy  wei-e  made,  however,  in  France, 
and  should  be  put  to  the  ci-edit  of  Desormeaux.  who  in  1853,  was  the 

25 


26  CYSTOSCOPY   Al^B    URETHROSCOPY 

first  to  examine  the  uretliral  and  vesical  mucosa  in  the  living  subject 
through  an  endoscopic  tuhe  in  the  urethra.  The  works  of  this  author 
actually  establish  the  beginning  of  endoscopic  study,  and  he  fully  de- 
serves the  title  of  "Father  of  Endoscopy"  which  has  been  bestowed 
on  him.  He  was  fully  justified,  too,  in  writing  on  the  covers  of  his 
treatise  on  endoscopy,  this  cry  of  triumph:  ''Nos  quoque  oculos  erudi- 
tos  habemus."     (Cic). 

In  1865  he  published  an  important  work  in  which  he  made  public 
the  results  of  his  experience.'  Desormeaux's  instrument  consisted  of 
a  series  of  tubes  of  different  calibers  and  lengths  which  were  introduced 
into  the  urethra.  The  source  of  light  was  a  petroleum  lamp;  the 
illumination  was  brought  into  the  interior  of  the  tube  by  a  reflecting 
mirror  pierced  in  its  center  and  inclined  to  an  angle  of  45  degrees  to 
the  tube.  This  apparatus  was  based  on  the  same  principle  as  that 
of  Bozzini. 

Desormeaux's  endoscopic  researches  became  well  laioA^m  and  at- 
tracted the  attention  of  other  investigators  to  such  an  extent  that  under 
this  stimulus,  similar  efforts  were  soon  multiplied  in  number ;  the  first 
that  appeared  were  those  of  Hacken*  in  1862,  and  of  Cruise'  in  1865. 

At  that  time,  the  principal  aim  was  to  increase  the  intensit}^  of  the 
light,  in  order  to  illuminate  the  lower  end  of  the  endoscopic  tubes. 
AYith  this  object  in  mind,  Furstenheim,  of  Berlin,^  substituted  gas  for 
the  petroleum  light,  and  Andrews,^  in  1867,  and  later  Stein^  employed 
a  magnesium  light. 

Up  to  the  time  of  Desormeaux,  all  the  attempts  to  inspect  the 
urethra  and  the  bladder  may  be  considered  together;  since  his  time, 
however,  a  clear  difference  must  be  established  between  those  who  de- 
voted themselves  especially  to  the  studv  of  the  urethral  mucosa  and 
those  who  attempted  to  inspect  the  bladder  particularly.  It  is  there- 
fore proper  to  make  a  separate  study  of  the  history  of  urethroscopy^ 
as  distinguished  from  that  of  cystoscopy. 

REPEEEISJ'CES 

iKasenelsolin :  Die  aSTormale  imd  Pathologisehe  anatomie  des  Talmua,  in  Eoberts'  Historische 
studien  aus  dem  Pharmakolgisclien  Institute  zu  Dorpat,  1896,  v,  p.  276. 

2Segalas:     Trans.  Acad.  Sc,  1826.     Traite  des  retentions  d 'urine,  Paris,  1828. 

sDesormeaux:  De  1 'endoscopic  et  de  ses  applications  au  diagnostic  et  au  traitement  des 
maladies  de  I'uretre  at  de  la  vessie,  Paris,  1865. 

*Hacken:     Dilatatorium  urethrge  zur  Urethroscopie,  Wien.  nied.  Wchnschr.,  No.  12,  1862. 

sCruise:     The  Utility  of  tlie  Endoscope,  Dublin,  Quart.  Jour.  Med.  Sc,  May,  1865. 

ePurstenlieim:  Berl.  klin.  Wchuschr.,  1870,  Nos.  3  and  4j  Oesterreich  Zeitschr.  fiir  Jahresb. 
Heilkr.,  No.  25,  1870. 

^Andrews:     The  Urethra  Viewed  by  Magnesium  Light,  Med.  Eec,  New  York,  1867,  ii,  p.  107. 

sStein:     Das  Photoendoscop,  Berl.  klin.  Wchnschr.,  1874,  No.  3. 


HISTORY    OF    URETHROSCOPY 


27 


HISTORY  OF  URETHROSCOPY 

Numerous  models  of  Tirctliroscopes  have  already  been  suggested, 
and  allliougli  ilic  list  ol'  existing  iiistruinciits  is  a  long  one,  it  is  still  far 
from  complete,  and  avo  nmst  expect  new  ones  to  appear  continually.  AVe 
may  classify  all  existing  uretliroscopes  into  two  quite  distinct  gi'oups: 
1.  Urethroscopes  with  external  illumination;  that  is,  whose  source  of 
light  is  situated  outside  of  the  urethroscopic  tuhe.  2.  Urethroscopes 
with  internal  illumination;  that  is,  with  tlie  source  of  light  situated 
inside  of  the  tuhe. 

Urethroscopes  with  External  Illumination 

This  group  itself  comjjrises  two   distinct   types   of  instruments: 

1.  Those  in  which  the  source  of  light  is  attached  to  the  urethroscope. 

2.  Those  in  Avhich  the  light  is  independent  of  the  urethroscopic  tuhe. 

1.  Urethroscopes  With  External  Illumination  Attached  to  the 
Urethroscopic  Tube. — The  first  apparatus  of  this  kind  was  constructed 
by  Desormeaux,  the  originator  of.  the  method.  Fig.  1  is  self-explana- 
tory.    This  j)rimitive  urethroscope  was  soon  improved  upon,  for  the 


Fig.   1. — Desonneaux's    urethroscope. 


illumination  A\'hich  was  furnished  by  an  oil  lamp  and  later  by  a  petro- 
leum lamp,  was  quite  insufficient  for  its  purpose.  The  electric  light 
eventually  gave  to  this  method  of  examhiation  the  position  it  deserves. 
This  important  im])rovement  to  Desormeaux's  urethroscope  was  con- 
tributed by  Horteloup  (Fig.  2). 

In  this  'same  group  of  instruments  nmst  also  be  mentioned  the 
following : 

(a)  The  panelectroscope  of  Leiter  (Fig.  3).  This  instiiunent  con- 
sists of  tubes  of  varying  calibers  and  lengths,  corresponding  to  No. 


28 


CYSTOSCOPY   AND    URETHEOSCOPY 


18  or  No.  20  Cliarriere,  which  are  introdnced  into  the  urethra  by 
tlie  aid  of  an  obturator  or  stylet.  Illumination  is  furnished  by  an 
electric  lamp   (B),  placed  in  a  semicylinder  open  on  its  upper  sur- 


Fig.  2. — Horteloup's  urethroscope.  The  cyl- 
inder containing  the  lamp  is  closed;  there  is 
a  concave  mirror  at  ^;  at  C  a  strong  lens  in- 
creases the  intensity  of  the  light  which  is 
reflected  upon  an  inclined  mirror  F,  thence 
carried  into  the  speculums,  which  are  held  to- 
gether by  a  metal  ferrule  E ;  at  the  extremity 
of  the  telescope  D,  is   a   group   of  lenses. 


0 


face;  the  light  is  thrown  upon  the  mirror  (D),  and  thence  reflected  into 
the  urethroscopic  tube  (A).  A  lens  (C),  which  can  be  adjusted  accord- 
ing to  one's  vision,  magnifies  the  field,  in  order  that  one  may  see  more 


^ 


Fig.  3. — Leiter's  panelectroscope.^ — It  is  open  above; 
the  light  is  reflected  upon  the  mirror  D,  into  the  specu- 
lum A;  a  lens    C,  magnifies  the  image. 


clearly  at  the  distal  end  of  the  tube.    This  instrument  has  been  again 
taken  up  by  Heitz-Boyer,  who  presented  it  to  the  Surgical  Society.^ 


HI.STORY    OV    IMtlCTIIltOSCOPY 


29 


Fig.   4. — Schutze's    diaphotoscope. 


Fig.   6. — Lang's   urethroscope. 


30 


CYSTOSCOPY   AITD    URETHROSCOPY 


'V\w  only  important  niodiiication  wliicli  lias  been  made  consists  in  the 
illuinination  whicli  is  similar  to  that  which  Brnnning  has  applied  re- 
('(•iil!\-  to  the  csophagoscope. 


Fig.   7. — Otis'    urethroscope. 


This  instrument  is  open  to  the  same  criticisms  which  may  he 
directed  against  all  nrethroscopic  instrmiients  having  external  illmni- 
nation  (see  page  35).  An  attempt  based  on  the  same  plan  was  made 
recently  by  Wyndham  Powell,^  who  constructed  a  urethroscope  with 


Fig.   8. — Casper's    electroscope. 


external  illumination  which  provided  parallel  rays  of  light.    With  this 

instrument,  examination  of  the  urethral  mucosa  requires  air  dilatation. 

Horteloup'  gave  up  the  use  of  Leiter's  panelectroscope  because  of 


niSTOFiV  OF   ri;i:Tiii;os('r)Tv 


31 


lis  iii('()ii\-('iiiGnces  aiKi  rciiiiiKMi  i 
iiK'niix,  iiii[)i'OVOcl  ^\'\\\\  ;iii  elect  lic 

()))   The  diaplioioscoix'  of  Scliulzc,  (Fi^-.  4). 

((0  Tlio  electroiirotliT()S('()i)o  of  Nyi'0})s  ( Kii;'.  r) 

(d)  TliG  urethroscope  of  Lang  (Fig.  G). 

(o)   Tlie  uvotliroseope  of  Otis  (Fig.  7). 

(f)   ^Hic  electroscope  of  Casix-r  (Fig.  S). 


he    |illlllil  i\  I'    Ill>1  lllllielil    of    I  )<'sor 

111). 


Fig.  9. — Antal's  aerourethroscopc 


(g)  The  aerourethroscope  of  Aiital  (Fig.  9).  Thi.s  instruiiu'iit 
contributed  another  iniprovenient.  It  Avas  designed  to  separati'  and 
distend  the  urethral  walls  to  their  iiiaxiiiiiim  exleiil.  1'lie  invthroscopic 
tube  is  closed  at  its  proximal  end  by  a  movable  AviiuU)\v  acting  like  a 
valve,  which  permits  air  to  be  forced  into  the  canal  of  the  urethra  by 
means  of  a  bulb.  During  the  examination,  the  window  retains  the  air 
ill  the  tube,  without  interfering  witli  vision  in  tlie  least:  meanwliile  nii 


32  CYSTOSCOPY   AXD    UEETHKOSCOPY 

assistant  makes  pressure  on  the  urethra  either  at  the  level  of  the 
)„Min.'iiin  ()!•  at  the  membrauons  urethra  through  the  rectum.  By  this 
,n..11i,.<l  111."  uretliral  walls  are  separated  by  the  pressure  of  tli^  air,  and 


Fig.   10. — Fenwick's    aerourethroscope. 

can  be  examined  over  an  area  of  several  centimeters.     Femvick,  of 
London,  modified  this  instrument  (Fig.  10). 

EEFEREK'CES 

iBull.  de  la  Soc.  de  Chirurgie,  Jan.  4,  1911,  p.  38. 

^Lancet,  London,  May  2-1,  1913,  p.  1463. 

■'•Hovtoloup:     Uretrite  dironique,  Paris,  Massou,  1892,  p.  43. 

2.  Urethroscopes  with  External  Illumination  Independent  of  the 
Urethroscopic  Tube. — Griinfeld,  of  Vienna,  originated  this  method  in 
1881.  He  introduced  a  tube  into  the  urethra  and  with  the  aid  of  a 
reflector,  he  projected  rays  of  light  into  its  lumen.  This  reflector, 
pierced  Avith  an  aperture  in  its  center,  permitted  the  observer  to  ex- 
amine the  urethral  mucosa.  As  a  source  of  illumination,  he  used  either 
the  sun's  rays,  diffused  daylight,  the  light  of  an  oil  lamp  or  gas,  or 
finally,  an  electric  lamp.  The  reflector  was  either  supiDorted  by  a 
handle  held  in  the  hand,  or  what  was  more  practical,  affixed  to  the 
forehead  of  the  observer  by  a  headband. 

Clar's  photophore  (Fig.  11)  constitutes  a  decided  improvement 
on  tlie  frontal  mirror  of  Giiinfeld.    It  consists  principally  of  an  elec- 


JTisTr)nv  OF  rnr/nrnosropv 


33 


trie  lain])  pliiccd  in  the  cciitci'  of  a  convex  miiror  wliidi  is  allacln'd  lo 
the  forcliead  by  a  lu'a(ll)aH<l. 

Tlio  Tirotliroscopic  tubes  wliicli  (iriinrdd  ('m))l<)y('d  \v('i-<'  cither 
straight  (Fig-.  12)  or  ciii-vcd.  lie  also  u^ini  stiaight  tulx-s  with  win- 
dows provided  witli  a  jcflecting  niiiroi-  (  Fcnstcrspiogclondoscop),  Fig. 
ll).     Tliis   iiistniincnt   consisted   ol'  an   oi(linar>-   metallic   tube   in   the 


Fig.   11. — Clar's   photophore. 

lateral  wall  of  which  was  an  opening  of  V/2  to  2  centiineters,  covered 
with  a  little  glass  window.  The  urethral  extremity  of  tlie  tube  Avas 
closed  with  a  metallic  tip,  to  which  was  attached  a  little  minor  at  an 
angle  of  45  degrees.  The  light  rays  which  penetrated  into  the  tube 
were  reflected  by  this  mirror  upon  the  lateral  window  of  the  tube  and 
the  operator  Avas  enabled  in  this  way  to  make  an  examination  of  the 
urethral  walls. 

Urethroscopic  tubes  have  been  modified  since  by  numerous  authoi-s. 


Fig.   12. — Urethroscopic    tube    and    its    obturator. 

Posner  has  recommended  glass  tubes  varnished  l)lack  inside,  to  i)i-evfnt 
the  reflected  ligiit  in  the  tube  from  dazzling  the  observer.  Tulx's  of  gum 
and  hard  rubber  have  also  been  reconmiended. 

AVith  the  object  of  enlarging  the  field  of  vision,  Ausi)itz  devised  a 
urethroscopic  tube  with  two  movable  valves  opening  into  the  urethra, 
so  as  to  obtain  the  maximum  view  of  the  urethral  nuu-osa  witiiout  at 


34 


CYSTOSCOPY   AND    URETHROSCOPY 


the  same  time  dilating  the  urinary  meatus.  This  idea  has  also  been 
utihzed  by  Oberlaender  and  by  Horteloup  (Fig.  14).  By  separating 
the  arms  of  the  tube  by  means  of  the  screw  D,  the  field  of  examination 
in  the  urethra  is  increased. 

Finally,  Janet  suggested  a  double  endoscopic  tube.  It  is  composed 
of  two  tubes,  one  sliding  into  the  other.    The  inner  tube  has  a  Avindow 


Fig.  ;13. — Griinfeld's   tube    with    window    and    mirror. 

which  permits  inspection  of  the  bladder  neck.  The  outer  is  an  ordinary 
urethroscopic  tube  open  at  both  extremities.  When  the  inner  tube  is 
removed,  the  outer  enables  the  observer  to  examine  the  urethra  in  the 
usual  manner. 

Quite  recently  tubes  have  been  constructed  according  to  the  sug- 
gestions of  Kollmann  and  Wiehe  (Fig.  15).  '  Their  object  is  to  permit 


(^ 


Fig.   14. — Horteloup's    bivalve    speculum.      By    removing   the    branches,    by    means    of    the   screw    D,    the   vis- 
ual field  at  the  bottom  of  the  urethra  is  increased. 

the  dilatation  of  the  distal  portion  of  the  tube  by  means  of  a  screw 
situated  at  its  outer  extremity,  in  a  manner  similar  to  the  dilatation 
of  the  horn  of  a  bagpipe.  But  this  method,  while  very  ingenious,  really 
gives  but  a  very  slight  enlargement  of  the  visual  field  and  the  slight 
advantages  which  are  thus  secured  hardly  compensate  for  the  incon- 
veniences of  the  method  which  are  due  to  its  complexity. 


n  I  STORY    OF    URETHROSCOPY 


35 


Advantages  and  Disadvantages  of  Urethroscopes  Having  Exter- 
nal Illumination. — Tlie  oulstandin^'  advaiila^'c  of  iii-elliroscojH's  willi 
external  illumination  is  that  manipulation  or  iiilcrveiitioii  in  the  in- 
terior of  the  tuhe  is  simplified.  The  cotton  carrier-  and  the  instruments 
Avhicli  are  introduced  into  the  tube  are  freely  nioval)le  and  do  not 
interfere  with  the  source  of  light.  Besides,  the  field  of  vision  is  cei-- 
tainly  somewhat  greater  than  in  the  case  of  internally  ilhiiiiiiia1<Ml 
urethroscopes,  in  which  the  lamp  occuioies  a  certain  amount  of  tlie 
lumen  of  the  tube. 

But  these  advantages  are  not  without  some  very  serious  incon- 
veniences. Principal  among  these  is  the  fact  that  they  do  not  iirovide 
a  clear  and  distinct  view.  However  intense  the  light  may  be,  it  is 
always  too  feeble  just  where  it  ought  to  be  strongest;  namely,  at  the 
bottom  of  the  tube.  Inasmuch  as  we  approach  the  source  of  light  as 
closely  as  possible  when  we  desire  to  see  an  object  well,  there  is  a 


Fig.   IS. — Kollmann-Wiehe   tubes. 

similar  reason  for  placing  the  illumination  as  near  as  possible  to  tlic 
urethral  mucosa.  We  may,  therefore,  conclude  that  internal  illumina- 
tion will  always  lorove  superior  to  external  illumination.^ 

In  order  to  convince  myself  of  this  fact,  I  have  made  a  series  of 
experimental  comparisons.  Holding  a  simple  tube  vertically,  I  tirst 
projected  into  it  the  rays  of  a  very  powerful  electric  light,  situated 
outside  the  tube  and  obtained  but  a  fairl}^  good  view  at  the  bottom  of 
the  tube.  On  the  other  hand,  when  I  substituted  for  the  external 
illumination  a  very  small  lamp  placed  directly  at  the  point  of  examina- 
tion, I  obtained  a  splendid  illumination  and  a  nmch  more  distinct  vicAv 
than  previously.  It  Avas  indeed  natural  to  expect  that  this  method 
would  furnish  a  light  superior  to  that  obtained  by  external  illnmi na- 
tion. Bringing  the  light  as  closely  as  possible  to  the  area  to  be  exam- 
ined is  by  far  the  most  favorable  condition  for  obtaining  a  satisfactory 
view.  A  beacon  light,  be  it  ever  so  powerful,  if  situatcnl  at  some  dis- 
tance from  the  surface  to  ])e  examined,  will  give  less  illumination  tlian 
a  simple  electric  light  placed  directly  over  it.     For  these  reasons,  I 


36  CYSTOSCOPY   AND    URETHEOSCOPY 

think  it  is  exercising  good  judgment  to  give  preterence  to  uretnro- 
scojDes  having  internal  illumination. 

Again  in  the  case  of  externally  illuminated  instruments,  such,  for 
example,  as  Clar's  photophore,  much  experience  and  considerable  ef- 
fort are  required  to  project  the  rays  of  light  into  the  interior  of  the 
tube.  Both  the  tube  and  the  mirror  being  movable  independently  of 
one  another,  the  operator  is  called  upon  to  maintain  a  fixed  and  steady 
position,  often  tedious  and  difficult,  in  order  to  derive  effective  results, 

"S^Hien  the  light  is  attached  to  the  proximal  (outer)  end  of  the  tube, 
the  lumen  is  obscured  and  a  view  is  obtained  only  by  the  aid  of  a 
mirror  perforated  in  its  center.  In  some  instances  the  apparatus  is 
arranged  with  a  system  of  reflection  by  a  mirror  and  lenses  which 
makes  the  handle  of  the  instrument  beavA^  and  renders  it  uncomfortable 
for  the  patient  and  difficult  for  the  surgeon  to  manipulate.  Intra- 
urethral  intervention  is  far  more  difficult  and  complicated,  for  it  can  be 
accomplished  only  with  tlie  aid  of  cumbersome  and  complex  instru- 
ments with  elbowed  shafts.  To  conclude,  it  does  not  appear  that 
urethroscopes  with  external  illumination  will  ever  be  made  that  Avill 
be  simple,  practicable  and  easy  to  manipulate. 

EEFEEEXCE 
-LuTs:     Bull,  fie  k  Soe.  de  I'Inteniat.,  Feb.  22,  1905,  p.  23. 

Urethroscopes  With  Internal  Illumination 

In  1879  Xitze  first  conceived  the  idea  of  introducing  the  source  of 
illumination  down  to  the  bottom  of  the  tube,  near  the  surface  to  be 
examined.'  This  is  undoubtedly  the  ideal  method  of  examination,  for 
as  he  puts  it,  "in  order  to  light  up  a  room,  one  must  carry  a  lamp  into 
it.'"  His  instrument  consisted  of  the  ordinary  urethroscopic  tube 
(Fig.  16)  in  the  wall  of  Avhich  were  three  minute  canals  or  channels. 
In  one  of  these  channels  was  an  electric  A\ire  which  led  do^^m  to  the 
lamp  placed  at  the  extremity  of  the  tube.  The  lamp  consisted  of  an 
incandescent  platinum  ^viYe.  The  two  other  canals  permitted  the  con- 
stant circulation  of  a  stream  of  water,  which  prevented  the  over- 
heating of  the  instrument.  This  primitive  instrument  did  not  prove 
to  be  practical,  however,  for  the  lamp,  being  too  large,  diminished  the 
visual  field  to  a  corresponding  degree. 

Subsequently  Leiter  and  particularly  Oberlaender  perfected  this 
interesting  method,  and  the  latter  deWsed  a  urethroscope  which  im- 
mediately showed  marked  superiority  to  all  that  had  been  employed 
previously.    Oberlaender 's  urethroscope  (Fig.  17)  affords  a  very  dis- 


HISTORY   OF    URETHROSCOPY 


37 


liiicl  \i('\v.  'riic  plaliimiii  wiic  wliidi  canics  llic  li.^lit  projcK'ts  l)ut 
slig'htlv'  into  Uh'  Iuiiicii  oi'  ilic  liilx-  aii<l  adniils  ol'  a  very  clear  vieAV  of 
a  rather  extensive  portion  of  llic  uiclliral  mucosa.  This  instrument 
has  two  great  disadvantages,  liowevcr;  iifst,  it  requii'cs  the  circuhitioii 
of  water  to  cool  the  himj),  thus  necessitating  an  expensive  and  conipli- 
calcd  outlii,  and  second,  it  compels  the  operator  to  withdraw  the  lamp 


Fig.   16. — Nitze's    urethroscope. 

from  the  tube  every  time  he  desires  to  make  a  local  application  to  tlie 
urethral  mucosa. 

Valentine,  of  New  York,  fortunately  corrected  these  faults  by 
replacing  the  platinum  incandescent  wire  with  a  very  small  electric 
bull)  mounted  on  a  thin  metallic  shaft  which  makes  it  possible  to  1)ring 
the  light  doAra  to  the  bottom  of  the  tube.  This  lamp  (Fig.  18)  is  sup- 
ported bv  a  handle  which  is  provided  with  a  current  interrupter 
(Fig.  19)^. 

Apart  from  this  modification,  wliich,  Ijy  the  way,  was  of  great 


Fig.    17. — Obcrlaciiilcr's    iircllnoscope. 

iin])oitance  in  its  time,  tlie  other  parts  of  Valentine's  uretiiroscope 
do  not  vary  materiallj^from  that  of  Oberlaender.  The  tube  and  its 
obturator  are  identical  with  the  Oberlaender-KoUmann  (Fig.  20).' 
Kollmann,  of  Leipzig,  has  adapted  tliis  instrument,  somewhat  modilied, 
for  taking  photographs  of  the  urethra.*  His  photographic  urethro- 
scope is  shown  in  Fig.  22. 

For  the  purpose  of  increasing  tlie  visual  lield,  Ivollmann  with  the 


38  CYSTOSCOPY   AND    URETHROSCOPY 

collaboration  of  Wiehe,  devised  a  movable  optical  apparatus  AvMch  was 
introduced  into  the  uretliroscopic  tube  and  attached  to  the  shank  of 
the  lamp  (Fig.  23). 

Wasserthal,  of  Carlsbad,  also  modified  the  Valentine  urethroscope 


Fig.    18. — Valentine's    uretliroscopic    lamp. 


by  adopting  Antal's  old  idea.  He  constructed  an  air  urethroscope 
designed  for  examination  of  the  urethral  mucosa  under  distention  mth 
compressed  air,  blown  into  the  urethra  (Fig.  24).  Although  this 
method  affords  an  excellent  profile  examination  of  a  large  portion  of 
the  urethral  mucosa,  it  has  the  disadvantage  of  not  ]3ermitting  a  front 
view  of  the  mucosa,  an  indispensable  need  in  many  instances.  Gordon, 
of  Vancouver,^  has  constructed  a  urethroscope  similar  to  the  one  just 
described  (Fig.  25). 


<^^i 


Fig.   19. — Valentine's    lamp    carrier. 

Valentine's  instrument  has  undergone  still  another  modification 
on  the  part  of  R.  Kaufmann  (Fig.  26).  This  author  attached  a  tele- 
scope in  front  of  the  urethroscope  thus  producing  an  enlargement  of 
the  urethral  view.  But  this  apparatus,  rather  heavy  and  cumbersome, 
presents  certain  difficulties  in  the  performance  of  operative  maneuvers 
within  the  tube. 

Demonchy's  recent  urethroscope  has  much  in  common  with  that 


Fig.   20. — Oberlaender-Kollmann    uretliroscopic    tube. 


of  Kaufmann,  differing  from  it,  however,  in  the  character  of  the 
handle.  This  handle,  twelve  centimeters  in  length,  presents  a  plano- 
convex achromatic  lens  which  gives  a  reversed  picture.  This  is  ex- 
amined and  magnified  through  another  lens,  the  eyepiece.    This  instru- 


iis'i'()i;>'   oi'    ri;i 


IIOSCOPY 


30 


iiH'iil  lias  doeidod  (lisadxanla^cs,  Ihc  principal  hcinu'  its  lack  oi'  siiii- 
])li('ity  (tlio  first  essential  of  a  good  iiistriuneiit)  ;  in  addition  the  handle 
is  diflicnlt  to  control  1)ecause  of  its  large  size.    A  second  disadvantage 


Fig.  21. — Valentine's  urethroscopic   outfit. 

is  fonnd  in  the  reversed  pictnre,  which  does  not  give  a  view  of  the 
objects  as  they  really  are.  All  in  all,  this  instrnment  is  too  complicated 
and  cumbersome  to  be  practicable. 

From  a  practicable  point  of  view,  Valentine's  instrnment  actiiall\- 
had  several  distinct  disadvantages.  Whenever  a  lamp  l)roke  oi-  Inii-iicd 
(Hit,  it  took  great  care  and  mnch  time  to  replace  it:  the  lam]i  itself  was 


^2^ 


mmitittudisiiim^^      mumtw  tT' ■•'■ 


Fig.   22. — Koliiiiann's    photographic    urethroscope. 


short-lived,  for  if  a  dro]i  ol'  linid  got  inside  of  its  little  metallic  sheallu 
a  short  circuit  was  established,  which  burned  it  out ;  though  the  ui-ethral 
lesions  could  be  seen  clearly,  they  might,  nevertheless,  occasionally 
remain  undiscovered  because  the  field  was  not  magnified;  lastly,  the 


40 


CYSTOSCOPY   AND    URETHROSCOPY 


little  lamp  and  its  holder  made  an  appreciable  projection  into  tlie 
Imnen  of  the  tube,  thereby  diminishing  the  visual  field  considerably. 
In  the  hope  of  remedying  these  disadvantages,  I  have  devised  a 
number  of  important  modifications  of  this  instrument,  the  first  of 
which  was  presented  before  the   Surgical   Society  on  December   24,- 


Fig.   23. — Handle    of    Kolluiaiin-Wiehe's    urethroscope,    provided    with    an    optic    apparatus. 

1902,  and  later  shoAoi  to  the  Academy  of  Medicine  by  my  teacher,  Le 
Dentu.'' 

1.  I  added  to  the  urethroscope  an  adjustable  lens,  the  focus  of 
which  corresponded  with  the  length  of  the  urethroscopic  tube.  The 
urethral  lesions  are  thus  magnified  and  none  of  them  can  possibly  be 


Fig.  2-1. — Wasserthal's    aerourethroscope. 

overlooked.  In  order  to  observe  the  picture  clearly,  the  presence  of 
the  magnifying  glass  is  really  very  useful,  and  makes  possible  the 
study  of  interesting  details  Avhich  can  readily  escape  the  unaided  eye. 
The  urethroscope  being  an  instrument  designed  especially  to  afford 
an  exact  diagnosis,  the  great  value  of  magnification  in  outlining  th,e^ 


ji  is'i'oi;^'  oi'   riii'rniijoscoi'v 


41 


details  and  cliaractcr  oi'  tiu!  urethral  mucosa  can  bo  readily  coniprc- 
iicndcd.  It  is  therd'orc  stra]i,ij,'e,  to  say  the  least,  tliat  certain  iii,<;('nuous 
observers  ai-e  unwillin,"-  to  avail  themselves  of  this  important  im- 
provement, on  llie  ,i;r()uii(l  that  tliey  are  obliged  to  i-ea<l,just  the  lens 
in  makini;'  local  ai)plications.     Moreover,  a  very  recent   inipi-o\-eiiient 


■^^""^■'^^^"'""""nn^^ 


afid-       immnmrjrnmmnrmmrrmmn,nn,n„. 


zin.inuiiiumu.iiiimumrunimmTmr^^ 


"■"■'■"•■" ■■'■    I'l  |'|(  "iifi;"!"' 


vi'i/iiiii  ii<rrii[ii"f""i"'ira(fL 


Fig.   25. — Gordon's    endoscope. 


makes  it  possible  for  endourethral  activities  to  ])e  undertaken  without 
adjusting  the  magnifying  lens  (see  page  45). 

This  lens  is  interchangeable  easily,  so  that  whether  the  operator 
is  myopic,  normal,  or  presbyopic,  he  can  have  a  special  lens  made  easily 


<Si 


rig.   26. — naudlc   ami    telcscupc   of    Kaufniann's   iirctlircscope. 

which  will  give  him  a  most  perfect  and  distinct  [)icture  with  the  least 
effort. 

2.  The  shank  of  the  lamp  carrier  has  l)een  [)erfected;  the  space 
l)etween  the  metallic  shaft  and  the  bulb  has  been  filled  in  so  that  not  a 
drop  of  fluid  can  enter  and  thus  bring  about  a  short  circuit. 


42  CYSTOSCOPY    AND    URETHROSCOPY 

^  3.  Changing  the  lamp  is  a  very  simple  procedure,  and  can  be  done 
in  a  few  seconds. 

4.  The  lamps  are  mounted  on  slender  rods  of  varying  lengths,  cor- 
responding to  long  or  short  nrethroscopic  tubes,  for  examination  of 
the  anterior  or  posterior  portions  of  the  urethra  respectively. 

5.  Finally,  at  my  suggestion,  the  nrethroscopic  tubes  have  been 
hollowed  out  throughout  their  entire  length  with  a  little  furrow,  in 
Avhich  the  lamp  and  its  carrier  are  retained  ^^uthout  interfering  with 
the  lumen  of  the  tube. 

REFERENCES 

iNitzo :     Eine  neiie  Beleuchtuiigs  iind  Uiitersucliungsmethode  f iir  Hariii'ohre,  Harublase  und 

Eectum,  Wien.  med.  Wchnschr.,  1879,  N'o.  24. 
2Nitze:     Lehrbuch  der  Kystokopie,  ed.  2,  Bergmann,  1907,  p.  8. 
sOberlaender  and  KoUmann:     Die  chronisehe  Gonorrhoe  der  mannlichen  Harnrohre,  Leipzig, 

1910,  p.  64. 
^KoUmann:      Die   photographie   des   Harnrohre  innern,   Centralbl.   f.    d.   Krankh.    d.    Harn-u. 

Sex.-Org.,  1891,  No.  391,  p.  227. 
•''Gordon:     Canadian  Med.  Assn.  Jonr.,  December,  1911. 
6Le  Dentu :     Bull,  de  1  'Acad,  de  med.,  Paris,  Session  of  July  4,  1905,  p.  4. 

In  concluding  this  subject,  it  is  fitting  to  mention  the  following, 
as  the  most  interesting  workers  in  the  field  of  urethroscopy : 

iDe  Keersmaecker  and  Verhoogen:      Uretrites  chroniques  d'origiue  gonoeoccique,  Bruxelles, 

1898. 
sClado:     Traite  d'liysteroscopie,  1898. 

sFenwick:     Obscure  Disease  of  the  Urethra,  London,  1902. 
4Kollmann:     Die  Photographie  des  Harnrohre  innern.  Centralbl.  f.   d.  Physiol,  .u.  Path.   d. 

Harn-u.  Sex.-Org.,  1891. 
sValentine:      The  Irrigation  Treatment  of  Gonorrhea,  New  York,  Wm.   Wood  &  Co.,   1900, 

p.  188. 
eAlbuquerque,  Azevedo:     Endoscopia  do  appareilho  urinario.  These  de  Porto,  1903. 
7Stern,  Charles:     On  the  Use  of  the  Urethroscope  in  Diagnosis,  Tr.  Connecticut  State  Med. 

Soc,  1906,  pp.  137-145. 
sAsch,  Paul:     Urethroskopische  Beitrage  zur  Diagnose  Therapie  und  Prognose  des  Trippers 

und  seiner  Folgen:   Ztschr.  f.  Urologie,  1907,  i.  No.  4. 
oLuys:     Diagnostic  et  traitement  uretroscopique  des  uretrites  chroniques,  Presse  med.,  April 
22,  1903;  Tr.  Assn.,  fran§aise  .d 'Urologie,  1903,  p.  789;  Endoscopic  de  I'uretre  et  de  la 
vessie,  Paris,  Masson,   1905,  Epuise;    Exploration  de  I'appareil  urinaire,   ed.   1  and  2, 
1909,  Paris,  Masson. 
loWossidlo:     Die  Gonorrlroe  des  Mannes  und  ihre  Komplicationen,  Berlin,  Otto  Emslin,  1903, 

ed.  2,  Georg  Thieme,  Leipzig,  1909. 
iiVon  Frisch  and  Zuckerkandl:     Handbiich  der  Urologie,  Wicn.     Holder,  1904,  i,  p.  550. 
i2Wormser:     Journal  des  Praticiens,  August  4,  1906. 
isSuarez  de  Mendoza:     Diagnostico  y  Tratamiento  de  las  enfermedades  de  las  Vias  urinarias, 

Madrid,  Perlado  Paez,  1908. 
iiOberlaender  und  Kollmaun :     Die  chronisehe  Gonorrhoe  der  Mannlichen  Harnrohre  und  irhre 

Komplicationen,  ed.  2,  Georg  Thieme,  Leipzig,  1910. 
isFraisse:     Gonorrhea  chronique  de  1 'Homme,  Paris,  Maloine,  1910. 

isHenry,  Eol)ert:      Instrumentation  et  technique   de  I'uretroscopie  posterieure.   Jour,   d 'Urol- 
ogie, iii,  1913,  p.  767. 


HISTORY    OF    URETHROSCOPY 


43 


i"Wossidl(),    pjvicJi:      Die   cliitniiHchcn    ErkiMnkuii^on    dcr    liinlcrcn    Hiiiiurilirr,    Rorlin,    Vorla^ 

Yon  Werner  Kliiikliardt,  191.",. 
isPiuil,  Auguste:      L'Uretr()seoj)ic,  TliT'Sc,  Paris,  Oilier  licniy,   IHKl. 


Description  of  Luys'  Urethroscope 

M)^  uretliroscopo  consists  of  two  distinct  parts:  1.  The  iiretliro- 
scopic  tuhes  and  their  obturators;  2.  The  handle  and  the  light  cari-ici-. 

Urethroscopic  Tubes. — The  tubes  present  for  examination  a  body 
or  shaft  and  two  extremities.  The  body  is  composed  of  a  tube  not 
perfectly  cylindrical  in  shape;  that  is,  on  one  of  its  walls  throne-bout 


Fig.    27. — lyuys'   long   cystoscopic   tube   and   its    obturator.      Inferiorly    can    be    seen    the    longitudinal   depres- 
sion for  the  lamp  and  its  shaft. 

its  entire  length,  a  small  groove  or  channel  is  found,  which  lodges  the 
lamp  and  its  carrier.  In  this  way,  instead  of  protruding  into  the  lumen 
of  the  tube,  the  lamp  and  its  carrier  are  hidden  in  the  thickness  of  the 
wall  and  become  a  part  of  it ;  this  increases  by  a  corresponding  amount 
the  inner  diameter  of  the  tube  and  accordingly  enlarges  the  visual 
field. 

One  of  the  extremities  of  the  tube  is  designed  to  articulate  Avith 


Fig.  28. — L,uys'  short  urethroscopic  tube  and  its  lamp. 


the  handle;  to  it  is  attached  a  large  circular  flat  collar  which  bears  a 
small  metallic  projection  upon  which  the  handle  is  afhxed  and  tightened 
mth  a  screw,  when  in  use.  A  slight  notch  in  the  margin  of  the  collar 
makes  the  handle  firm  and  immovable.  The  other  extremity  is  blunt, 
in  contrast  with  the  German  tubes,  in  order  to  protect  the  urethral 
mucosa  from  possible  damage. 

Length  of  the  Tubes. — The  tubes  I  usually  employ  are  of  varied 
lengths,  depending  on  the  particular  part  of  the  urethra  to  lie  examined. 
The  long  tubes  are  14  cm.  long  (Fig.  27).  They  are  designed  espocially 
for  examination  of  the  posterior  uretlira.     The  short  tubes  (Fig.  28) 


44  CYSTOSCOPY   AND    URETHKOSCOPY 

designed  for  the  penile  (anterior)  urethra,  are  7  cm.  long.  The  me- 
dium-sized tubes  are  most  frequently  used;  they  measure  13  cm.  in 
length. 

Caliber  of  the  Tubes. — To  determine  the  most  desirable  caliber 
for  the  urethroscopic  tube,  Oberlaender  and  Kollmann  examined  three 
hundred  patients,  and  out  of  this  number  they  found  that  only  two  or 
three  per  cent  had  a  meatus  too  small  to  admit  a  No.  23  Charriere, 
while  in  the  great  majority  of  cases  (69  to  70  per  cent)  No.  27  and  even 
No.  29  was  admitted  easily.  They  concluded  that  No.  23  must  be  used 
in  10  per  cent  of  patients,  and  No.  25  in  25  per  cent  of  patients.  These 
investigations  show,  therefore,  that  the  greatest  number  of  patients 
have  a  meatus  sufficiently  large  to  admit  at  least  No.  25.  My  personal 
observations  are  in  absolute  accord  ^yith.  these  figures,  so  that  in  most 
cases  I  use  a  No.  26  tube. 

In  a  general  way,  it  may  be  said  there  is  a  decided  advantage  in 
using  the  largest  possible  tube,  for  the  surface  to  be  examined  is 
thereby  stretched  and  the  folds  of  the  mucosa  disappear,  so  that 
minute  lesions  which  would  othermse  be  obscured,  are  brought  to  view. 

Material  Used. — The  tubes  which  I  use  are  of  metal,  nickel-plated. 
Tubes  of  this  kind  are  most  easily  cleaned,  sterilized,  and  handled. 
Some  operators  iDref er  glass  tubes,  because  they  are  nonconductors.  A 
short  circuit  may  sometimes  occur  when  the  metallic  lamp  carrier  is 
introduced  into  a  metallic  tube,  and  the  current  turned  on,  but  this 
can  easily  be  avoided  if  certain  precautions  are  taken.  On  the  other 
hand,  however,  the  fragile  nature  of  glass  tubes  gives  ground  for  fear 
that  they  might  break  while  in  the  canal  and  produce  serious  injury. 
Griinfeld,  among  others,  has  recommended  hard  rubber  tubes;  but 
these  tubes  do  not  seem  to  have  au}^  advantage  over  the  metal  ones. 

The  obturators,  as  opposed  to  those  of  German  make,  are  full- 
plated  metallic  rods.  Their  manipulation  and  withdrawal  from  the 
tube  offer  no  difficulties  of  any  kind.  In  my  first  models  a  small  groove 
ran  along  the  entire  length  of  the  obturator,  for  the  passage  of  a  cur- 
rent of  air  on  withdrawal  of  the  obturator  after  the  tube  had  been 
introduced.  This  prevented  the  urethral  mucosa  from  being  aspirated 
into  the  bottom  of  the  tube.  There  was  neither  trauma  nor  j)ain.  This 
plan  did  not  prove  practicable,  however,  and  I  have  since  had  the 
wall  of  the  tul^e  grooved  along  its  entire  length,  thus  securing  all  the 
benefits,  without  the  disadvantages,  of  the  groove  on  the  obturator. 

The  Handle. — The  handle  consists  of  a  metallic  body  long  eiiough 
to  offer  a  good  purchase  for  the  hand,  and  provided  with  an  interrupter 
designed  to  make  and  l^reak  the  electric  current.  The  electric  wires 
which  carrv  the  current  are  attached  to  its  lowei'  extremitv.     At  the 


HISTORY    OF    URETHROSCOPY 


45 


upper  end  is  a  inagiiifying  lens,  easily  moval^le  from  side  to  side  in  a 
transverse  direction.  This  lens,  engaged  in  a  small  metallic  circnlar 
liolder,  is  easily  demountable,  so  that  it  can  he  changed  readily  to 
correspond  with  the  size  of  tnhe  emplo3^ed.  Each  size  of  tnhe  has 
its  corresponding  lens,  the  focus  of  which  is  exactly  suited  to  the 
length  of  the  tube. 

Some  observers  have  felt  obliged  to  criticize  my  .employmeni  of  this 
lens,  which  they  declare  interferes  with  a  clear  urethral  view.  "The 
field  is  seen  very  well  with  the  magnifying  glass,"  they  say,  ''but  if 
we  wish  to  treat  the  mucosa  and  we  move  the  lens,  we  can  no  longer 
see  the  details  so  well  as  before,  and  the  local  treatment  becomes  more 
difficult  of  application."    To  overcome  this  objection  I  have  very  small 


Fig.  29. — Handle  of  L,uys'  urethroscope,  show- 
ing the  magnifying  lens  and  the  wires  (front 
view). 


Fig.  30. — Improved  model  of  the  handle  of 
Luys'  urethroscope,  in  which  the  lens,  much  re- 
duced in  size,  need  not  be  turned  aside  during 
endo urethral    manipulations. 


lenses  made  which  are  maintained  in  place  by  a  metallic  frame  attached 
to  a  slender  holder  (Figs.  29  and  30).  Instruments  can  be  introduced 
into  the  urethroscope  alongside  the  margin  of  tliis  lens.  The  latter, 
having  the  same  diameter  as  that  of  the  lumen  of  the  tube,  may  re- 
main stationary,  not  only  for  observation  of  the  uretliral  nmcosa,  but 
likewise  in  making  local  applications  to  the  nmcosa.  The  lens,  because 
of  its  small  size,  does  not  offer  the  slightest  interference  Avith  intra- 
urethral  manipulations  and  applications. 

With  this  simple  optical  system,  it  is  no  longer  necessary  to  dis- 
])lace  the  magnifying  lens  in  the  case  of  eiidourethral  interventiim,  and 
it  is  at  the  same  time  possible  to  preserve  the  magnifuation  j^crlVclly 
Ih  rough  out  the  examination. 


46 


CYSTOSCOPY   AXD    URETHEOSCOPY 


Finally,  tlie  small  electric  lamp  is  attaclied  to  the  tuoe,  mounted 
on  a  carrier  of  Yar^dng  length,  in  accord /\^"itli  the  length  of  the  tube. 
The  light  carriers  are  measured  exactly  so  that  the  electric  bulh  approx- 
imates the  lower  extremity  of  the  tube,  T\'ithout,  lioweYer,  coming  into 
contact  with  the  mucosa.  The  ease  and  rapidity  ^^^.th  which  a  lamp  can 
be  changed  or  replaced  are  very  strildng  indeed,  only  a  few  moments 
being  sufficient  for  the  purpose. 

Urethroscopic  tubes  are  sterilized  by  boiling :  the  lamps  are  steril- 
ized like  the  cystoscopic  lamps;  i.  e.,  in  formalin  [or  alcohol — Editor]. 

This  is  the  instrument  I  have  always  operated  with  and  with  com- 
plete satisfaction.  It  answers  any  criticism  that  may  be  made  regard- 
ing it.    The  danger  of  a  burn  is  absolutely  nil,  for  the  cold  lamps  em- 


Eig«   31. — Profile   view    of    Luys'    urethroscope    (complete^. 


ployed  give  forth  no  appreciable  heat  Avhile  they  are  new.  In  all  the 
examinations  I  have  made,  no  patient  has  ever  complained  of  any  dis- 
agreeable sensation  of  heat.  From  this  point  of  view  it  is  well  to  change 
the  lamp  frequently  and  to  have  a  stock  always  on  hand,  for  they  are 
quickly  used  up,  and  whereas  AYhen  new,  they  are  absolutely  cold,  so 
that  they  may  be  held  between  the  fingers,  while  lighted,  YAithout  any 
perception  of  heat,  it  is  nevertheless  true  that  after  they  have  been  used 
for  some  time  they  become  hot  and  have  to  be  replaced.  In  buying 
these  lamps,  only  those  having  the  smallest  caliber  and  Avhicli  are  abso- 
lutely cold  should  be  selected.  On  the  other  hand,  enclourethral  manip- 
ulations are  cpiite  possible  with  the  lamp  in  situ.  AU  manipulations  are 
done  under  the  eye  of  the  operator.  Lastly,  illunnnation  of  the  urethral 
mucosa  is  perfect  and  far  superior  to  that  furnished  by  urethroscopes 
with  external  illumination. 


HISTORY    or    UrvETIlROSCOPY 


47 


Special  Urethroscopes  for  the  Posterior  Urethra 

Because  of  the  protrusion  of  the  veruniontaiium  into  the  urethra, 
the  examination  of  the  posterior  portion  of  the  canal  presents  special 
difficulties.  The  tip  of  a  straight  tube  strikes  against  the  anterior 
prominence  of  the  verumontanum  (Fig.  32),  so  that  certain  precau- 
tions are  required  to  prevent  its  interference  with  the  introduction  of 
the  instrument.  This  accounts  for  the  many  modifications  adox)ted  by 
various  authors ;  namely,  elbowed  instruments  and  distention  of  the 
posterior  urethra. 

■  Goldschmidt  conceived  the  idea  of  using  water  for  the  purpose  of 


Fig.   32. — Illustrating 


V  r^jtAfrj 


prominence    of    the    verumontanum    arrests    and    obstructs    the    extremity    of 
the  urethroscopic   tube. 


dilatation;  Wossidlo,  following  Antal,  employed  air.  For  my  own 
part,  after  having  tried  endless  improvements  designed  to  secure 
a  better  knowledge  of  the  posterior  urethra,  I  have  given  up  tliese 
complicated  instruments  entirely  and  have  given  preference  to  u\y 
simple  tube.  Handled  cautiously,  this  tube  has  always  in  its  favoi-  its 
enviable  simplicity  and  the  extreme  facility  -\\'ith  which  it  is  managed. 
Goldschmidt's  Irrigation  Urethroscope  for  the  Posterior  Urethra. 
— This  instrument  (Fig.  35)  is  both  interesting  and  useful  in  the  ex- 
amination of  the  deep  urethra.  It  resembles  a  model  previously 
adopted  by  Le  Fur  (Figs.  33  and  34).  In  1903  Le  Fiir  presented  a 
urethroscope  which  was  characterized  by  the  fact  that  the  lamp  was 
attached  to  the  end  of  the  urethroscopic  tube  as  in  the  cystoscope. 


48 


CYSTOSCOPY    AND    URETPIROSCOPY 


While  tliis  arrangement  had  the  advantage  of  providing  an  nnob- 
strncted  lumen  in  the  tube,  it  had  the  drawback  that  the  eye  of  the 
operator  was  dazzled  by  receiving  the  light  rays  directly  against  it, 
and  as  a  result,  the  details  of  the  mucosa  could  not  be  distinguished 
clearly/ 

This  idea  was  taken  up  by  Goldschmidt,  of  Berlin,-  who,  in  1906, 


Fig.   33. — L,e   Fiir's   urethroscopic   lamp. 

devised  an  interesting  urethroscope,  with  which  excellent  results  can 
be  obtained  in  special  cases.  He  dilated  the  walls  of  the  urethra  with 
water  under  hj^drostatic  pressure  and  thus  examined  the  urethral  mu- 
cosa. His  instrument  consists  of  two  parts,  one  for  the  anterior  ure- 
thra, the  other  for  the  posterior ;  each  of  these  contains  an  optical  sys- 


7 


dC: 


^ 


M: 


Fig.   34. — L,e    Fiir's    urethroscope. 

tem  which  brings  a  rather  large  portion  of  the  urethra  under  observa- 
tion, by  enlarging  the  field  of  vision. 

Techjstic. — After  emptying  the  bladder  naturally,  the  patient  is 
put  in  the  position  for  cystoscopy;  the  head  low,  body  horizontal,  the 
buttocks  at  the  edge  of  the  table,  the  thighs  flexed,  and  the  heels  sup- 


Fig.  35. — Goldschmidt's   posterior   urethroscope. 

ported  by  stirrups  or  footrests.  The  instrument  and  its  obturator 
having  been  sterilized  and  lubricated  with  glycerin,  it  is  introduced  as 
far  as  the  posterior  urethra,  which  it  enters  readily  because  of  its 
elbowed  tip.  The  electric  cable  is  connected  with  the  rheostat,  and 
the  stopcock  at  the  upper  end  of  the  tube  is  connected  with  an  irri- 
gating   jar   containing   warm   water    [preferably    a    mild    antiseptic 


TTISTOKY    or-    rr.RTHROSCOPY  49 

solulioii — l^]i)i'i'()i;  I  ('lc\'nl('(l  ahoiil  Iwo  iiiclci's  ahoNc  llic  level  of 
tJK'  lahic.  ''I'lie  ohtiiralor  is  llieii  w  it  lidiaw  ii  and  the  optical  slieatli  or 
t<'l('S('o])e  is  iiisei-1e(|  and  t iuhteiied  in  place.  This  hciiig  donci,  the 
stopcock  is  opened,  tlie  eh'ctric  cnirent  tui'iied  on,  and  tlie  posterior 
iirctlii'a  is  now  examined  l»y  niovini;  the  instiaunent  to  and  fro  and 
rotatin.u'  it,  as  iHupiired,  The  water  runs  naturally  into  the  l)ladder; 
when  the  latter  ])ecomes  i'uU,  the  patient  feels  a  desire  to  urinate. 
The  current  is  tuiiied  off,  the  stopcock  closed,  the  telescope  is  with- 
drawn and  tlie  \\atei-  in  the  bladder  is  permitted  to  escape  into  a 
di-ain  attached  to  the  tal)le.  Goldschniidt  has  also  devised  an  an- 
terior urethroscope  based  on  the  same  princiiDle   (Fig.  36). 

Advantages. — This  instrument  has  notable  advantages.  A  com- 
plete examination  of  the  posterior  urethra  is  made  possible  mthout 
interference  by  the  presence  of  blood,  the  latter  being  constantly 
carried  off  by  the  stream  of  water  into  the  bladder.  Besides,  the 
walls  of  the  posterior  urethra  are  well  separated  from  one  another, 
thus  giving  a   clear  view   and   distinct   landmarks.     Lastly  the   pic- 


<^^p< 


Fig.   36. — Goldschmidt's    anterior    urethroscope. 


tures  are  greatly  magnified  and  the  smallest  details  are  discernibh^; 
even  the  smallest  polj^pi  float  in  the  water  and  are  easily  recognized. 

Disadvantages. — Uyiifortunately  the  disadvantages  of  this  instru- 
ment are  more  numerous  than  the  advantages.  To  begin  with,  the 
apparatus  is  complicated  necessarily.  The  management  of  the  optical 
system  and  the  essential  presence  of  the  current  of  water  make  this  in- 
strument anything  but  a  simple  one.  Again,  the  urethroscopic  pictures 
are  not  seen  as  they  really  are;  the  mucosa  is  white,  pale,  and  bloodless, 
for  the  water  exerts  pressure  on  it  which  i)roduces  a  localized  anemia. 
Afoi'eover,  it  is  impossible  with  this  instrument  to  get  a  complete  view  of 
the  entire  posterior  nrethra  at  one  time.  Only  one  wall  of  the  urethra 
can  be  seen  at  once,  for  an  entire  half  of  tlie  lumen  of  the  instrument 
is  taken  up  by  the  lamp.  The  supcM'ior  wall,  above  the  verumontanum, 
can  not  be  examined  at  all,  and  this  is  a  sei-ious  defect.  Finally,  the 
endourethi'al  intei-ventions,  such  as  local  a])i)lications  and  cauteriza- 
tion, are  rather  impractical  and  dithcult  with  this  instrument. 

Summary. — Though  this  instrument  is  excellent  for  examination 


50  CYSTOSCOPY   AND   URETHROSCOPY 

purposes,  its  employment  seems  to  be  limited  to  those  comparatively 
few  cases  in  which  it  is  desired  to  acqnire  exact  pathologic  details  of 
the  posterior  nrethra.  Alfred  Rothschild^  has  devised  some  interesting 
modifications  of  Goldschmidt's  instrument. 

Buerger's  Cystourethroscope. — Buerger,'*  of  New  York,  has  im- 
proved upon  Goldschmidt's  instrument  by  devising  an  apparatus  which 
is  based  on  the  same  principles  as  those  of  Nitze's  first  cystoscope  (Fig. 
37).  The  defects  which  he  finds  in  the  Groldschniidt  instrument  are  the 
limited  field  of  vision,  distortion  of  the  pictures,  and  difficulty  of  manip- 
ulation because  of  the  traumatism  which  it  causes. 

Buerger's  instrument  does  not  possess  these  disadvantages;  the 
pictures  are  magnified  by  virtue  of  a  prism  situated  on  the  upper?  wall 
of  the  instrument. 

Technic. — The  tube  armed  with  its  obturator  is  inserted  into  the 
bladder;  the  latter  is  emx^tied  through  the  tube,  and  the  telescope  is 
inserted  on  withdrawal  of  the  obturator.    The  stream  of  water  is  intro- 


Fig.   37. — Buerger's   cystourethroscope. 

duced  by  a  lateral  stopcock  connected  with  an  irrigator  filled  with  warm 
antiseptic  solution.  The  electric  current  is  now  turned  on.  The  trigone 
is  first  examined,  next  the  posterior  urethra,  the  fluid  being  injected 
only  from  time  to  time.  Not  more  than  50  to  150  c.c.  of  fluid  may  be 
necessar}^  The  instrument  can  be  turned  in  every  direction  because  of 
the  smallness  of  its  mndow. 

This  is  essentially  an  examination  instrument  and  is  not  practicable 
for  endourethral  work.  This  cardinal  fault  necessarily  restricts  its 
usefulness. 

Wossidlo's  Posterior  Urethroscope.— In  1908  Wossidlo'  devised  an 
instrument  (Fig.  38)  for  x)osterior  urethroscopy  in  which  air  Avas  used 
for  dilatation  of  the  canal,  but  in  a  more  recent  model  he  also  employs 
water  for  this  purpose.  This  instrument  undoubtedly  presents  a  clear 
and  distinct  detailed  view  of  the  urethral  mucosa,  but  it  also  has  im- 
portant disadvantages.  The  principal  one  is  that  the  instrument  does 
not  give  a  true  picture.  The  object  under  examination  is  deformed  by 
the  optical  system  with  its  great  magnification,  to  such  an  extent  that 


HISTORY    OF    URETIIUOSCOPY 


51 


tlio  i-oal  condition  of  the  mucosa  can  not  he  (Ictciiiiiiiod  accurately. 
There  is  anotliei-  great  drawback,  in  tliat  it  is  impossible;  to  operate  on 
tlie  lesions  that  tiie  instrument  reveals,  because  the  optical  apparatus 
interferes  with  the  iiitiMxhidion  and  manijinlatioii  oC  instruments 
within  the  urethi'oscopic  tube,  so  that  when  therapeutic  intervention  is 
attempted,  the  telescope  must  be  removed;  the  mucosa  previously  mag- 
nified is  now  only  dimly  visible  by  the  unaided  eye. 

Donnnei',  oi*  Dresden,  attempted  to  remedy  these  disad\  antages. 
He  devised  an  optical  apparatus  whicli  pei-niits  tlie  use  ol'  an  elect  rode. 
a  curette,  and  a  Instoury,  while  the  apparatus  is  in  position.  The 
entire  outfit  is  introduced  in  a  Wossidlo  urethroscopic  tube;  naturally 


Fig.   38. — Wossidlo's    posterior    urethroscope. 

the  diameter  of  the  tube  is  increased  by  several  num1)ers,  thus  render- 
ing its  ]-outine  emplo^mient  rather  difficult. 

Summary.— Wossidlo's  apparatus,  like  that  of  Goldschmidt  and 
Demonchy,  is  complicated,  the  principal  fault  being  that  the  optical 
apparatus  is  heavy  and  diflicult  to  manipulate. 


REFEEENCES 

iLe  Fiir:     Tr.  Assn.  fran^aise  d 'Urologie,  p.  784. 

-Goldschmidt:      Die  Endoscopic  der  Hainvcihre,  Boil.   klin.  Wcluischr.,   Feb.  5,   190(>.  No.  fi ; 

Die  Irrigations  Urotroskopie,  Folia  Urologica,  von  .Tames  Israel,  1907,  i,  Nos.  1  and  2. 
:iRnthscliild:      Ztsehr.  f.  Urol.,  190S,  ii,  ]^.  TOOO;  VitIuhkH.  d.  deuLscli.   Gesellsch.  f.  Urologio. 

II  Kongress  in  Berlin,  April,  1909,  p.  45S. 
^Buerger,  Leo:     On  Methods  of  Posterior  Urethroscopy,  with  a  Description  of  a  new  Tysto- 

urethroscope,  Am.  Jour.  Surg.,  May,  1910. 
■■Wossidlo:     Ztsehr.  f.  Urol.,  190S,  p.  124:1;  Deutsdi.  iiic.l.  W.4ni.schr..   1910.  No.  7. 


PLATE  I 

Fig.  1. — Normal  appearance  of  the  prostatic  fossette  (postmoiitane  space) 
situated  between  the  bladder  neck  and  the  verumontanum.  Below,  the 
apex  of  the  posterior  wall  of  the  verumontanum  can  be  seen;  above, 
can  be  seen  the  orifice  of  the  bladder  neck  from  which  longitudinal 
folds  descend  in  fan  shape. 

Fig.  2. — Normal  appearance,  anterior  vieiv  of  the  verumontanum,,  in  which 
the  prostatic  utricle  is  distinctly  seen.  The  upper  part  of  the  urethral 
mucosa  is  finely  corrugated  and  constitutes  a  valuable  landmark  in 
determining  the  shape  and  size  of  the  verumontanum.  This  is  the 
most  common  view  observed. 

Fig.  3. — Another  normal  aspect  of  the  verumontanum,  in  which  the  pros- 
tatic utricle  is  not  visible.  Above  are  seen  the  corrugations  of  the 
urethral  roof  above  the  verumontanum;  below,  the  anterior  frenum  of 
the  verumontanum  is  recognized. 

Fig.  4. — Normal  appearance,  anterior  aspect  of  the  verumontanum,  when 
the  urethroscopic  tube  has  been  brought  forward  anterior  to  the  pre- 
ceding figure.  The  protrusion  of  the  verumontanum  has  diminished  in 
height  and  width;  in  front  of  the  verumontanum,  its  frenum  is  clearly 
seen;  above,  on  the  roof,  the  corrugations  have  increased  the  thick- 
ness of  the  mucosa  appreciably. 

Fig.  5. — Appearance  of  a  very  considerably  hypertrophied  (juasturbator's) 
verumontanum.  The  organ  here  takes  on  the  appearance  of  the  uterine 
neck. 

Fig.  6. — Normal  appearance,  anterior  surface  of  the  verumontamm.  The 
prostatic  utricle  is  not  visible,  but  on  the  lateral  walls  of  the  veru- 
montanum, two  orifices  are  seen  corresponding  to  the  ejaculatory  ducts 
(resembling  a  diver's  helmet). 


ri«.  1. 


VvA.  2. 


Fig.  3. 


Fis.  4. 


PLATE  I 


Fig.  6. 


HISTORY    OF    URETHROSCOPY  53 

Personal  Experience  with  the  Posterior  Urethroscope. — The  ex- 
cellent results  obtained  with  my  direct  vision  cystoscope  and  recto- 
scope  induced  me  to  adopt  the  same  principles  of  examination  for  the 
posterior  urethra.  I,  therefore,  undertook  a  series  of  experiments  and 
made  attempts  to  improve  upon  the  instruments  devised  for  this  pui-- 
pose.  I  constructed  a  tube  similar  to  my  direct  vision  cystoscope; 
that  is,  provided  on  its  lower  inner  surface  with  a  fine  canal  Avhich  was 
open  at  the  end  of  the  tube  and  connected  Avith  tAvo  stopcocks  on  the 
outside.  Through  this  tiny  canal  it  was  possible  to  aspirate  fluids  or 
inject  air  by  means  of  a  rubber  bulb.  Illumination  Avas  proAdded  by  a 
small  electric  lamp  mounted  on  a  long  stem  or  carrier.  A  small  sheet 
of  glass  mounted  on  a  metallic  brace  assured  closure  of  the  small  orifice 
by  adapting  itself  by  pressure  to  the  external  orifice  of  the  tube.  This 
glass  AvindoAv  Avas  to  be  used  solely  in  connection  Avith  insufflation  of 
the  posterior  urethra. 

Ada^antages. — ^AVhen  air  Avas  forced  into  the  deep  urethra  under 
pressure,  perfect  vision  Avas  obtained ;  it  was  like  a  cloud  being  dissi- 
pated, a  disappearing  shadoAv,  leaving-  a  perfect  illuminated  AdeAv  of  the 
A'erumontanum.  Moreover,  swabbing  Avith  cotton  AA^as  rarely  needed, 
for  the  presence  of  the  air  Avas  quite  sufficient  to  dry  up  the  slight 
oozing  of  blood  and  even  the  pathologic  secretions.  Inasmuch  as  the 
Avails  of  the  urethra  Avere  Avidely  separated  from  one  another,  a  com- 
plete vieAV  of  the  entire  posterior  urethra  AA^as  thus  obtained. 

Another  great  advantage  over  the  Avater-dilated  instruments  lay 
in  the  fact  that  the  operator  Avas  not  annoyed  by  the  presence  of  air 
bubbles  Avhich  interfere  Avith  distinct  vision  b}^  filtering  through  the 
Avater.  The  color  of  the  mucosa  Avas  hardly  altered;  it  Avas  not 
blanched  as  is  the  case  Avith  the  Avater  urethroscopes  and  its  appear- 
ance Avas  practically  normal. 

Disadvantages. — The  air  Avhich  served  to  dilate  the  posterior 
urethra,  passing  directly  into  the  bladder,  constituted  the  principal 
disadvantage.  The  bladder  soon  became  full,  resulting  in  a  charac- 
teristic desire  to  void  the  urine.  AVhen  the  prostate  Avas  small,  noth- 
ing could  be  easier  than  to  pass  the  tube  gently  into  the  bladder,  open 
the  tube,  and  evacuate  the  Adscus  in  this  Avay.  But  Avhen  the  prostate 
Avas  someAvhat  enlarged,  it  became  a  difficult  iiiatlci'  to  ('iii])ty  tlic  blad- 
der in  this  manner.  This  is  certainly  a  disadvantage:  the  prostate 
formed  a  valve,  so  that  the  air  entered  readily  but  could  not  escape. 

To  obviate  this  draAvback,  I  modified  my  first  apparatus  by  curA'- 
ing  its  vesical  extremity  so  as  to  permit  its  passing  more  easily  into 
the  bladder;  I  also  placed  a  small  opening  at  the  end  of  the  curA^e 
Avhich  permitted  the  air,  under  pressure  in  the  bladder,  to  be  evacu- 


54  CYSTOSCOPY   AND   URETHROSCOPY 

ated  easily  through  the  stopcocks  on  the  outside  of  the  tube.  The 
posterior  urethra  A¥as  quite  easily  examined  with  this  instrument. 
Frankly  speaking,  however,  there  are  certain  cases  in  which  special 
methods  of  exploration  are  required,  whichever  instrument  may  be 
employed. 

In  the  vast  majority  of  instances,  my  simple  urethroscopic  tube 
is  quite  sufficient  to  make  a  complete  examination  of  the  posterior 
urethra,  pro^dded  it  is  employed  only  after  a  thorough  dilatation  of 
the  urethra  with  Benique  sounds.  The  view  thus  obtained  is  perfect 
and  we  derive  all  the  advantages  of  the  special  instruments  Avithout 
enduring  their  disadvantages.  Finally,  when  in  certain  very  special 
cases  it  is  necessary  to  examine  the  region  of  the  bladder  neck  and 
especially  its  urethral  sides,  my  direct  vision  cystoscope,  male  model, 
is  preferable  to  any  other  instrument  (see  page  225). 

I  venture  to  express  the  hope  that  the  facility  of  management, 
precision  of  view  and  certainty  of  diagnosis  which  my  urethroscope 
affords,  will  induce  many  physicians  to  return  to  urethroscopy,  for 
many  of  the  most  zealous  have  had  to  abandon  this  valuable  method 
of  investigation  after  their  first  efforts,  because  of  the  difficulties  in 
manipulating  the  instruments  previously  employed.  If  urethroscopy 
has  been  employed  but  little  in  France  up  to  the  present,  the  partic- 
ular reason  must  be  found  in  this  fact  that  the  instruments  put  at  the 
disposal  of  physicians  have  really  been  ver^^  clmnsy  or  else  ver^^  com- 
plicated. I  still  think,  after  twelve  years  of  experience,  that  my  instru- 
ment deserves  preference  over  other  existing  models,  both  for  examina- 
tion and  therapy,  because  it  possesses  the  cardinal  features  which  Ave 
have  a  rig:ht  to  demand  of  any  instrument;  namely,  it  is  simple  and 
practicable. 

HISTORY  OF  CYSTOSCOPY 

The  first  attempts  to  examine  the  vesical  mucosa  through  the 
natural  passages  were  made,  as  Ave  haA^e  seen,  in  the  beginning  of  the 
nineteenth  centurA^  At  first  all  the  investigators,  following  the  lead 
of  Desormeaux,  sought  to  project  light  rays  into  the  interior  of  a  hol- 
loAV  tube  inserted  into  the  bladder.  But  soon  afterAA^ards,  different 
and  more  complicated  procedures  made  their  appearance  in  rapid 
succession. 

Cruise,  of  Dublin,^  in  1865,  substituted  an  elboAved  tube  for  the 
straight  one.  This  tube  had  an  obtuse  angle  and  was  provided  Avith  a 
mirror  at  its  angle.  The  instrument  consisted  of  tAvo  tubes,  one  of 
Avhich,  a  straight  one,  slid  into  the  interior  of  the  other.  The  inner 
straight  tube  had  a  little  glass  screen  at  its  vesical  end,  Avhich  pre- 


HISTORY    OF    CYSTOSCOPY  55 

vented  the  fliii<l  in  tlio  bladder  fi-oiii  oljstructiiii;-  tlio  field  of  vision. 
The  inner  tube  lioin^-  movable,  the  l)ladder  could  be  emptied  readily 
when  the  fluid  interfered  with  distinct  vision. 

In  an  earlier  model,  Cruise  had  a  glass  Avindow  at  the  vesical 
end  of  his  tul)e;  but  wben  the  light  was  reflected  strongly  upon  tlie 
mirror,  it  dazzled  the  operator  and  interfered  with  his  viev,^  of  the 
bladder.  In  a  second  model,  he  closed  the  terminal  extremity  of  his 
tube  completely  and  placed  the  glass  window  almost  at  right  angles 
with  the  mirror.  In  this  way  the  light  and  visual  rays  were  both  re- 
flected at  45  degrees  and  he  thus  obtained  a  reflected  picture  of  the 
bladder,  and  even  the  bladder  neck  could  be  examined  in  this  wa3^ 

The  principle  adopted  by  Bruck,-  of  Berlin,  in  1867,  was  quite  dif- 
ferent. Bruck's  diaphanoscope  aimed  to  illuminate  the  bladder  indi- 
rectly. It  was  made  of  two  distinct  parts;  the  first  consisted  of  a 
poAverful  light  emanating  from  an  incandescent  xolatinum  mre,  water- 
cooled.  It  had  to  be  introduced  into  the  rectum  and  was  designed  to 
illuminate  the  posterior  wall  of  the  bladder.  The  second  part  of  the 
apparatus  was  a  simple  hollow  metallic  tube  which  was  introduced  into 
the  urethra  up  to  the  bladder  and  permitted  inspection  of  the  vesical 
mucosa.  Unfortunately  this  method  did  not  furnish  sufficient  illumina- 
tion of  the  bladder  wall,  and  a  clear  i^icture  was  therefore  impossible. 
It  was  soon  given  up  and  discarded. 

Matters  stood  thus  when  the  lamented  Professor  Xitze,  in  187fi. 
began  his  study  of  the  subject;  and  we  must  here  acknowledge  that 
this  inventor  rightfully  deserves  first  place  in  the  history  of  cystos- 
copy because  of  his  epoch-making  work  on  this  subject. 

The  new  idea  Avhich  he  contributed  and  which  differed  radically 
from  those  of  his  predecessors,  was  that  instead  of  employing  exter- 
nal illumination,  as  they  had  done,  he  brought  the  light  into  the  blad- 
der itself;  in  his  o^Am  words,'  ''in  order  to  light  up  a  room,  it  is  neces- 
sary to  bring  the  lamp  along  with  you." 

However,  in  view  of  the  narrow  canal  leading  into  the  bladder,  it 
became  necessary  to  develop  a  method  which  would  permit  magnifi- 
cation of  the  visual  field,  before  this  idea  could  be  made  really  prac- 
ticable. Nitze  himself  tells  the  circumstances  in  which  this  problem 
was  solved.  One  day,  in  the  hospital  at  Dresden,  while  examining 
the  objective  of  a  microscope  to  see  whether  it  Avas  cleai'.  lie  looked 
through  the  lens  at  a  neighboring  clmicli.  Ife  saw  only  a  streak  of 
liffht.  Immediately  the  idea  occurred  to  him  that  he  could  easily  ob- 
tain an  enlargement  of  the  visual  field  willi  a  system  of  lenses.  His 
i-esearches  soon  led  to  a  system  made  up  of  lV)ur  lenses  combined  with 
a  prism. 


56  CTSTOSCOPY    AXD    UEETHEOSCOPT 

As  a  source  of  liglit.  Xitze  first  made  use  of  an  incandescent 
platinnm  film  ^^itli  Avliicli  lie  obtained  a  very  good,  clear  light.  Tliis 
had  the  disadvantage.  hoAvever.  of  requiring  circulation  of  Avater  in 
order  to  aA'oid  burning  the  mucosa.*  This  primitiA'e  instrument  AA^as 
im]DroA^ed  and  made  more  practicable  through  the  aid  Avhich  Ijeiter, 
of  Vienna,  gave  him  in  1879:  and  the  name  Xitze-Leiter,  has  been 
given  to  this  early  model.  This  instrument  Avas  complicated.  hoAv- 
ever,  by  the  fact  that  the  essential  presence  of  Avater  jDroA^ed  imprac- 
ticable because  of  the  difficulty  of  protecting  the  platinum  AAure  loop. 

Conditions  remained  thus  until  the  discoA^ery  of  the  Edison  lamp. 
Applied  inunediately  to  cystosco^Dy  by  Xitze.  this  modification  brought 
a  great  imx^roA-ement  to  the  original  instrument,  and  in  18S7  Xitze 
constructed  his  final  cystoscope  Avhich  is  the  underlying  basis  of  all 
modern  instruments.    In  this  Avay,  prismatic  cystoscopy  had  its  birth. 

EEFEEEXCES 

iCruise:     Tlie  Endoscope  as  an  Aid  iu  the  Diagnosis  and  Treatment  of  Disease:   The  Utility 

of  the  Endoscope,  Dublin  Quart.  Jour.  Med.  Sc.  May  1.  1865. 
2Bruck:     Das  L'retroscop  und  das  Stomatoscop  zur  Durchleuchtung  der  Blase  und  der  Zahue 

und  ilirer  Xachbartheile  durch  galvanisches  Gliihlicht.  Breslau,  1867. 
sXitze:     Lehrbuch  der  Kystoskopie,  Wiesbaden,  Bergmann,  1907,  ed.  2,  p.  8. 
4]Sritze:     Eine  neue  Beleuchtungs  und  Untersuchungsmethode  fiir  Harnrolire,  Haiuljlase  und 

Kectum.  AVieu.  med.  AVchnsehr..  1879.  Xo.  24. 


History  of  Direct  Vision  Cystoscopy 

Coincident  Avith  the  researches  of  Xitze  and  his  folloAvers.  other 
iiiA'estigations,  of  equal  interest,  Avere  being  conducted.  At  Vienna 
Griinfeld,  in  1881,  taking  up  the  principle  of  Desormeaux's  method, 
attempted  to  make  a  direct  examination  of  the  bladder  in  both  sexes 
by  means  of  a  straight  tube  liaAung  external  frontal  illumination.  But 
the  conditions  under  AA-hich  he  made  his  examinations  of  the  A'esical 
caAdty  Avere  so  imperfect  that  he  deriA^ed  but  slight  adA'antage  from 
them.  He  actually  looked  at  the  A'esical  mucosa  through  a  stratum 
of  urine  Avliich  he  did  not  InioAv  Iioav  to  eliminate.  Xeither  could  he 
distinguish  the  ureteral  orifices  except  in  a  A^ery  imperfect  manner, 
at  least  in  the  male  subject.  Later  on.  lu^  published  reports  of  this 
method  of  cystosco^Dy  in  the  treatment  of  l)ladd(^r  tumors  in  the  male 
and  female.^ 

HoAvever,  considerable  progress  folloAved  Griinf eld's  efforts,  and 
he  Avas  soon  aide  to  remoA'e  bladder  tumors  by  the  natural  routes  and 
eA'en  succeeded  in  catheteriziu"-  the  ureters  in  the  female.    All  of  these 


HISTORY    OF    CYSTOSCOPY 


57 


efforts,  liowever,  were  merely  stepping-stones  in  tlie  direction  of  di- 
rect vision  cystoscopy. 

To  Kelly,"  of  Baltimore,  whose  work  goes  Ijack  to  1893,  l)elongs 
the  honor  of  having  emphasized  the  importance  of  this  method  and 
of  having  indicated  its  great  possibilities.     Kelly  made  use  of  simple 


Fig.  39. — Kelly's   endoscopic   tube. 


tubes  provided  with  minute  canals  in  their  Inmen,  into  which  he  sent 
Imninous  rays  by  means  of  an  external  illumination  attached  to  the 
forehead  of  the  examiner.  To  dilate  the  bladder  in  the  female,  he 
had  recourse  to  atmospheric  air.     He  had  previously  observed  that 


vim 


Fig.   40. — Method    of   holding    Kclly"s    endoscopic    tube. 


the  abdominal  viscera  are  influenced  by  gravit>'  in  the  genupectoral 
position,  and  are  draA\'n  doAmwards  towards  the  diaphragm.  This 
creates  a  tendency  to  a  vacuum  in  the  small  pelvis  which  is  made  evi- 
dent by  a  sudden  and  complete  dilatation  of  the  bladder.  When  a 
hollow  tube  was  introduced  into  the  urethra  penuitting  the  entrance 


58 


CYSTOSCOPY    AND    UEETHEOSCOPY 


.of  air  into  tlie  bladder,  the  latter  became  distended,  to  nse  Ms  OA^^l 
expression,  "like  a  balloon  tilled  with  air."  Kelly  employed  this 
method  in  women  with  brilliant  snccess. 

In  1898  he  published  a  report  on  catheterization  of  the  ureters  in 
the  male  ^yith  an  open  c3^sto scope.' 

Pawlick,  of  Prague,*  constructed  a  direct  \dsion  cystoscope,  in 
1898,  which  consisted  of  a  speculum,  provided  Avitli  a  handle  (Figs. 
41  and  42).  He  placed  the  patient  in  either  the  genupectoral  or  Tren- 
delenburg position,  which  brought  about  the  distention  of  the  bladder 
by  the  entrance  of  air.  "With  this  instrument  Pawlick  examined  the 
vesical  ca^dty  under  the  direct  illumination  of  sunlight.     AVhen  the 


Fig. 


41 — Pawlick's    endoscopic 
tube    and    obturator. 


Fig.   42. — Pawlick's    endoscope   with    its    lamp    and    irrigating 
apparatus. 


latter  was  not  available,  he  employed  electric  illumination  jDro^dded 
vdtlci  an  irrigation  apparatus  for  cooling  purposes. 

Kelly's  work  stimulated  further  improvements  which  were  soon 
applied  practicalh^  in  his  instruments.  One  of  the  most  interesting 
was  the  improvement  of  Garceau,  of  Boston,"  who  was  the  first  to 
evacuate  the  bladder  urine  through  an  accessory  canal  included  in 
the  body  of  the  urethroscopic  tube  adapted  to  the  female.  Pie  con- 
structed an  instrument  of  this  kind  (Fig.  43)  in  1895.  He  soldered  an 
accessory  tube  of  tine  caliber  into  a  cystoscopic  tube  so  that  when  the 
handle  of  the  latter  was  turned  toward  the  right  side  of  the  patient 
the  accessory  tube  was  rotated  to  the  inferior  Avail  of  the  speculum. 
The  urine  was  then  aspirated  by  a  Davidson  syringe  the  bulb  of 
which  could  be  held  by  the  hand  which  held  the  handle  of  the  speculum 


HISTORY    OF    CYSTOSCOPY 


59 


SO  that  an  assistant  was  not  required.  The  simple  idea  of  aspirating 
the  urine  as  it  was  being  secreted  into  the  liladder,  Avas  sure  to  appeal 
to  those  Avho  were  using  this  instrument,  and  it  soon  had  many  imi- 
tators. In  Europe  it  was  our  distinguished  confrere,  Hogge,  of  liege, 
who  devised  a  similar  instrument  for  use  only  in  the  female,  in  1897.'' 
In  this  instrument,  the  aspirating  canal,  also  soldered  to  the  cysto- 
scopic  tube,  was  joined  on  the  outside  to  a  rul)ber  tube  which  termi- 
nated in  a  receptacle  into  wliicli  the  urine  drained  automatically. 
Through  the  courtesy  of  its  inventor,  I  exhibited  this  instrument  at 
the  Urological  Congress  of  1905. 


@= 


Fig.  43.- — Garceau's  endoscopic   tube  with   its   urine  aspirator. 


Very  curious  and  quite  groundless  is  the  claim  of  De  Keers- 
maecker,  of  Antwerp,^  who  claimed  for  himself  priority  of  this  im- 
provement. As  a  matter  of  fact,  his  first  paper  appeared  two  years 
after  Garceau's  first  paper^  and  more  than  six  montlis  later  than 
Hogge 's  first  article,  while  De  Keersmaecker  passed  over  both  eom- 
nmnications  of  his  predecessor  in  silence. 

Other  interesting  changes  were  made  by  way  of  perfecting  Kel- 
ly's combination  of  instruments.  Among  these,  attention  may  now 
be  called  to  the  interesting  cystoscope  devised  by  Bransford  Lewis, 
of  St.  Louis,  who  described  his  instrument  and  the  technic  of  its  use 
before  the  Association  of  Genitourinary  Surgeons.    The  Lewis  cysto- 


60 


CYSTOSCOPY    AXD    URETHROSCOPY 


scope  consists  of  a  tube  to  which  are  attached  a  handle  and  a  beak, 
the  latter  enclosing  a  small  cold  electric  lamp.  The  instrmiient  is 
introduced  into  tlie  bladder  with  the  aid  of  an  obturator,  which  is  then 
mthdrawn.  The  jDroximal  end  of  the  tube  is  capj)ed  A\T.th  an  eyepiece 
composed  of  a  single  lens  which  corrects  the  inversion  of  the  picture. 

To  dilate  the  bladder,  Lewis^  introduces  warm  air  which  is  re- 
tained under  pressure  by  a  stopcock.  Special  channels  are  attached 
for  the  passage  of  ureteral  catheters.  Finally,  to  insure  magnifica- 
tion of  the  image  as  well  as  of  the  visual  field,  a  telescope  is  intro- 
duced Avhich  consists  of  a  series  of  lenses  and  a  prism. 

Technic. — The  i)atient  lies  with  the  pelvis  raised  somewhat.  The 
cystoscope  is  introduced,  the  obturator  Adthdra^m,  the  bladder  emp- 
tied of  urine  and  the  glass  cap  applied  over  the  orifice  of  the  tube. 
Warm  air  is  now  introduced  into  the  bladder  to  distend  it  and  the 


Fig.   44. — Cullen's  cystoscope,  without  its  optical  part,  the  lamp   reversed,   emitting  vertical  rays  downward. 

electric  current  turned  on.  In  this  way  the  bladder  may  be  examined, 
taking  the  precaution  to  aspirate  the  urine  from  the  bladder  from 
time  to  time  ^Adth  a  syringe.  Single  or  double  catheterization  of  the 
ureters  ma^^  thus  be  easily  accomplished. 

In  1903  Thomas  CuUen"  devised  a  bent  cystoscopic  tube  con- 
taining no  optical  apparatus  in  its  interior,  but  provided  with  an 
inverted  lamp  at  its  elbow  which  emitted  vertical  luminous  rays  from 
above  do^mward  (Fig.  44).  This  instrument  was  the  basis  of  a  more 
complicated  and  impracticable  instrument  presented  nevertheless  as 
original  to  the  Surgical  Society  of  Paris  in  May,  1905.  It  does  not 
appear,  however,  that  this  apparatus  can  give  satisfactory  results. 
Indeed,  every  cystoscopic  tube  with  an  immovable  elbow  has  a  two- 
fold defect.  On  the  one  hand,  intravesical  mp.nipulation  is  difficult 
for  the  surgeon  and  painful  to  the  patient,  the  elbow  preventing  easy 


HISTORY   OF    CYSTOSCOPY  61 

movement  of  the  instrument  within  the  bladder;  on  the  other  Inmd, 
with  such  an  instrument,  only  the  base  of  the  bladder  is  visible,  and 
the  remainder  of  the  viscus  remains  unexplored. 

These  two  principal  faults,  which  are  of  serious  character,  ren- 
dered an}"  possible  additional  effort  in  this  direction  practically  use- 
less. In  point  of  fact  there  is  undoubtedly  a  great  advantag-e  in 
maintaining  the  straight  form  for  the  endoscopic  tube.  Its  clean-cut 
edges  permit  the  localization  of  a  point  such  as  the  ureteral  orifice 
and  bringing  it  into  the  interior  of  the  tube,  just  as  the  uterine  cervix 
is  brought  within  the  lips  of  the  vaginal  speculum. 

In  France  direct  vision  cystoscopy  has  been  practiced  but  little, 
and  up  to  the  present  but  few  authors  have  adopted  it.  One  of  the 
first  works  on  the  subject,  is  that  of  Janet"  who,  in  1891,  devised  a 
double  endoscope,  consisting  of  an  internal  tube  provided  AAith  a  win- 
dow which  fitted  into  the  interior  of  an  outer  tube.  AVith  this  appa- 
ratus Janet  succeeded  in  examining  the  vesical  mucosa.  He  inserted 
the  instrument  directly  up  to  that  portion  of  the  bladder  which  was 
to  be  examined  or  treated,  and  on  withdrawing  the  inner  fenestrated 
tube,  he  thus  obtained  the  bladder  area  upon  which  he  could  operate 
through  the  remaining  external  tube  mthout  the  escaiDe  of  the  dis- 
tending fluid. 

In  1898  Clado''  recommended  the  Trendelenburg  position  for  dis- 
tending the  female  bladder.  Paul  Delbet,'"  in  1902,  devised  an  endo- 
scope with  blades  that  spread  out  like  a  fan  within  the  bladder  owing 
to  a  mechanism  constructed  on  the  principle  of  the  iris  diaphragm. 
This  instrument  could  be  used  only  in  the  female.  Moreover  the  steel 
blades  did  not  always  approximate  exactly  at  the  end  of  the  examina- 
tion, and  sometimes  nipped  the  mucosa,  doing  more  or  less  damage. 
In  brief,  this  instrument,  though  ingenious,  was  a  delicate  affair,  and 
thus  failed  to  attain  general  popularity.  In  1902  Clarence  Webster/^ 
of  Chicago,  and  in  1903,  Hartmann''  also  reconmiended  the  Trendelen- 
l)urg  iDosition  for  the  examination  of  the  female  bladder. 

I  began  to  study  this  question  in  1902,  after  liaving  completed  my 
urethroscope,"  when  I  immediately  attempted  to  extend  its  field  of 
usefulness  from  the  urethra  to  the  bladder.  But  it  was  not  until  Octo- 
ber, 1904,  that  I  presented  before  the  Congress  of  Urology  a  direct 
vision  cystoscope  which  gave  me  excellent  results  in  the  examination 
of  the  female  bladder."  Applying  later  to  tlie  male  what  I  first  ac- 
complished for  the  female,  I  constructed  a  direct  vision  cystoscope 
for  the  male  Avhich  was  presented  to  the  Surgical  Society  on  March  1, 
1905.''  My  results  and  observations  Avere  announced  in  my  Avork  on 
"The  Endoscopy  of  the  Urethra  and  Bladder"  which  appeared  in 


bZ  CYSTOSCOPY   AXD   URETHROSCOPY 

April,  1905."  This  work  was  presented  before  the  Academy  of  Med- 
icine by  my  former  teacher,  Le  Dentu.-°  In  June,  1905,  I  described 
my  instrument  and  its  technic  in  the  Presse  medicale-^  and  in  the  An- 
nates de  gynecologie  et  d'obstetriquer^ 

The  splendid  results  obtained  through  direct  vision  cystoscop^^ 
with  my  instrument  were  described  in  the  Annates  cjenito-urinaires.^^ 
In  October,  1905,  I  reported  in  detail  to  the  Congress  of  Urology  the 
recent  improvements  in  my  instrument  which  produced  an  image  and 
illumination  far  superior  to  those  previously  attained.-*  In  Novem- 
ber, 1905,  I  demonstrated'-'  the  valuable  aid  which  nw  direct  vision 
cystoscope  gave  in  seeking  foreign  bodies  in  the  bladder  and  I  showed 
the  ease  with  which  such  bodies  even  of  large  size  could  be  removed 
from  that  organ.^*^  As  a  cro^^ming  of  my  efforts  in  this  direction,  the 
Faculty  of  Medicine  late  in  1905  did  me  the  honor  to  award  the  Bar- 
bier  prize  for  my  direct  vision  cystoscope.  Since  then  I  have  con- 
tinued to  study  the  question  and  have  profited  by  the  lessons  of 
experience  to  learn  the  great  advantages  which  can  be  derived  from 
this  interesting  method. 

In  1906^^  the  results  attained  with  the  direct  ^T^sion  cystoscope 
were  pointed  out  and  further  elaborated.^^  In  1907  the  simple  treat- 
ment of  bladder  tumors  was  described.^^  In  1909  the  great  advan- 
tage of  direct  vision  cystoscopy  in  searching  for  ureteral  calculi  was 
demonstrated,'"  and  three  years  later  the  treatment  of  phosphatic 
bladder  stones  was  described.^^  A  resume  of  the  advances  in  direct 
vision  cystoscopy  has  been  published  recently.'^ 

Since  my  first  publications,  many  papers  have  been  written  and 
numerous  modifications  have  been  suggested  for  my  instrument.  Jean 
Ferron,  of  Bordeaux,  thought  that  in  certain  circumstances  it  would 
be  advisable  to  shorten  the  male  cystoscopic  tubes.  Instead  of  18  cm. 
which  my  cystoscope  measures,  Ferron  employed  tubes  15  cm.  in 
length  and  at  times  he  even  employed  tubes  measuring  only  l.S  cm. 
The  change  in  length  has  the  advantage  of  improving  the  view,  for 
the  nearer  we  approach  the  object  to  be  observed,  the  more  clearly 
the  details  appear.  In  the  same  way,  Ferron  made  tubes  of  varying 
calibers,  even  up  to  No.  48  Benique.  These  modifications  are  of  in- 
terest, and  must  be  used  only  in  certain  cases. 

Among  the  other  articles  which  have  given  most  attention  to  this 
subject,  the  following  may  be  read  with  profit'  Those  of  Boari'"  of 
Ancona ;  Bickersteth  f^  Gauthier,'^  of  Lyons ;  and  finally  the  very  in- 
teresting thesis  of  P.  Jardon,'*^  which  appeared  at  Bordeaux  in  1912, 
in  which  the  author  shows  that  ''in  many  cases  direct  vision  can  be 
employed  in  the   same  way  and  with  the   same   advantages  as   the 


TTTSTOTIY    OK    CYSTOSCOPY  bo 

prism."     As  lie   rurllici-  rciiini-ks,  llic  use  of  dii-cci   x'isioii  cystoscopy 
"should  Ix'  iiioic  widespread  tliau  it  is  at  present." 

REFERENCES 

iGriinfekl:       Ueber    Cystoskoiiic    ini     All-cim  iiicn     und     iilicr    I'.liisciit  iiiiior(Mi    irii     Besomlcrji, 

Wieii.  klin.  Wclmschr.,  1889,  No.  21,  p.  42;!. 
^Kelly:     Bull.  Johns  Hoi^kiiis  Hosp.,  December,  189:5;  Am.  .loiir.  Obst.,  Jaimaiy,  1894;  ibid., 

July,  1894,  No.  85. 
:iKelly:     Cystoscopy  and  Catheterization  of  the  Uietcrs  in  the  Male,  Ann.  Surg.,  April,  1898. 
4Pa\vlick:     Zentralbl.   f.  Gyuac,   1896 j   Revue   gynecol.   d    diii'.   abdoni.,   October,  1897,  pp. 

786-822. 
nGarceau:     B^oston  Med.  and  Surg.  Jour.,  Oct.  1?,,  1895,  p.  444. 
eHogge:      Cystoscope   a   lumiere  externe   pour   le   catheterisme   permanent   des  ureteres   chez 

la  femme,  Soc.  med.-chir.  de  Liege,  April  1,  1897;  Ann.  Soc.  med.-chir.  de  Liege,  June, 

1897. 
7De  Keersmaecker :     Societe  beige  d'Urologie,  June  6,  1905. 

8De  Keersmaecker:     Ann.  Soc.  beige  de  Chir.,  Dec.  18,  1897,  v,  Nos.  5  and  6,  pp.  165,  166,  167. 
oLewis:     Jour,  of  Cutan.  and  Genito-Urin.  Dis.,  1900,  p.  420. 
if'Cullen:     A  Simple  Electric  Female  Cystoscope,  Bull.  Johns  Hopkins  Hosp.,  June,  1903. 
n Janet-:     Un  nouvel  endoscope  uretro-cystique,  Ann.  d.  mal.  d.  org.  genito-urin.,  1891,  p.  627; 

Revue  generale  d.   Sciences,   March  15,   1892. 
isClado:     La  cystoscopie   dans  le  diagnostic  des   affections   de  la  vessie   chez   la  femme,   Tr. 

Assn.  frang.  d'Urologie,  1893,  p.  333. 
]3Delbet:      Speculum   endo-vesical  pour  I'examen   du   trigone  et   du  bas-fond   chez  la  femme, 

Tr.  Assn.  fran§.  d'Urologie,  1902,  p.  679. 
i4Webster:     J'our.  Am.  Med.  Assn.,  May,  1902. 
isHartmann:      La  cystoscopie   directe   chez  la  femme,  in   Travaux   de   ehirurgie  anatomo-cli- 

niques,  Paris,  Steinheil,  1902,  p.  43. 
leLuys:     Bull,  et  mem.  Soc.  de  chir.  de  Paris,  Dec.  24,  1902;  Presse  med.,  April  22,  1903. 
i-Luys:      Tr.   Assn.   franQ.   d'Urologie,    1904,   p.    522;    De    I'application   de   1 'uretroscopie   a 

I'examen  de  la  vessie  et  au  traitement  des  cystites  de  la  femme. 
i.sLuys:     Bull,  et  mem.  Soc.  de  chir.  de  Paris,  March  7,  1905,  pp.  224  and  244. 
i9Luys:     Endoscopic  de  I'uretre  et  de  la  vessie,  Paris,  Masson,  1905.     (Out  of  print.) 
2oLe  Dentu:     Bull,  de  I'Acad.  de  med.,  Paris,  July  4,  1905,  p.  4. 
2iLuys:     La  cystoscopie  a  vision  directe,  Presse  med.,  June  24,  1905,  p.  39. 
22Luysi     La  cystoscopie  directe  chez  la  femme,  Ann.  d.  gynee.  et  d 'obst..  May,  1905,  p.  292. 
23Luys:     Ann.  genito-urin.,  July  15,  1905. 
24Luys:     Tr.  Assn.  fran^,.  d'Urologie,  1905,  pp.  467-482. 
25Luys:     Presse  med.,  Nov.  29,  1905;   Rev.  prat.  d.  mal.   d.  org.  genito-urin.  du  Dr.   Gallois, 

January  1,  1906. 
26Luys:     La  Clinique,  Octav  Doin,  editor,  April  13,  1906,  p.  230. 

27Luys:     Nev^^  Direct  Vision  Cystoscope,  Paris  Med.  Jour.,  April,  1006.  i.  No.  1,  April,  190(). 
28Luys:     Des  indications  de  la  Cystoscopie  a  vision  directe,   Tr.   10th   session  Assn.   fran^. 

d'Urologie,  October,  1906,  p.  382. 
-•iiLuys:     La  Cystoscopie   a  vision   directe   dans  lo   traitonient    des   tunu'urs   de   la   vessie,   Tr. 

11th  session,  Assn.  fran?.  d'Urologie,  October,  1907,  p.  407. 
:i"Luys:     La  cystoscopie  a  vision  directe  dans  la  recherche  des  calculs  tie  Turetere,  Tr.   l.'Uli 

session,  Assn.  fran^.  d'Urol'Ogie,  OetoluM-,  11MI9,  ]\  2iti>. 
3iLuys:     La  Cystoscopie   a   vision    directe   dans    h'    Iraitcnicnl    des   caknils   phosphatiques,    Tr. 

16th  session  Assn.  franc.  d'Urologie,  Octolicr.   1912,  p.  694. 
•■•2Luys:      Ueber  die  direkte  Cystoskopio,  Ztschr.  f.  Uroiogische  Chir.,  March   7,  191.3,  i.  Parts 
1  and  2,  p.  103. 


64  CYSTOSCOPY   Aj^D    URETHROSCOPY 

ssBoari,  (d'Ancone)  :  Estratto  degli  Atti  della  Societa  italiana  di  Urologio,  Congresso  di 
Eoma,  April,  15,  16,  1908 ;  Ann.  d.  mal.  d.  org.  genito-urin.,  1908,  ii. 

34Bickersteth :     Catheterization  of  the  Ureters  and  Its  Uses,  Lancet,  London,  May  18,  1912. 

35Gauthier :  Indications  de  la  Cystoseopie  a  vision  directe,  Ann.  d.  mal.  d.  org.  genito-urin., 
1910 ;  Lyon  nied.,  April  11,  1909. 

36Jardon:  De  la  Cystoseopie  a  vision  directe  sel-on  les  procedes  modernes.  These  Imprimeria 
Moderne,  A.  Destout,   Senior   &  Co.,  Bordeaux,   1912. 


CHAPTER  II 
URETHEOSCOPY 

Importance  of  Urethroscopy. — Urethroscopy  may  he  defined  as 
the  study  of  the  urethral  mucosa  under  the  direct  control  of  the  eye 
by  the  aid  of  the  urethroscope.  In  order  to  attain  an  exact  idea  of 
the  utility  of  urethroscopy,  and  of  the  su]oreme  importance  of  the  di- 
rect examination  of  the  urethral  canal,  it  is  necessary  to  understand 
fully  the  great  service  which  this  method  of  examination  can  render 
in  the  diseases  of  the  urethra,  and  especially  in  that  disease  which 
is  most  frequent;  namel}^,  chronic  urethritis. 

Urethroscopy  in  Chronic  Urethritis. — We  know  now  that  chronic 
urethritis  is  a  purely  local  disease  and  that  the  foci  of  infection 
which  perpetuate  and  prolong  it  are,  in  the  vast  majority  of  cases, 
thoroughly  localized  and  circumscribed.  A  thorough  knowledge  and 
understanding  of  these  foci,  so  that  they  may  be  treated  according 
to  their  respective  varieties,  constitute  the  secret  of  the  cure  of 
chronic  urethritis.  The  instruments  and  the  methods  designed  to  ex- 
plore the  urethra  and  its  adnexa  have  been  numerous,  and  have  been 
employed  over  a  long  x>eriod  of  time;  and  among  the  methods  of  ex- 
X)loration,  urethral  endoscopy  possesses  a  value  of  the  highest  order 
both  in  the  diagnosis  and  the  treatment  of  urethral  disease. 

The  urethroscope  is  for  the  urethra  what  the  stethoscope  is  for 
the  heart,  Avhat  the  roentgen  rays  are  for  fractures,  what  the  lar- 
yngoscope is  for  the  larynx,  what  the  ophthalmoscope  is  for  tlie  eye. 
While  the  stethoscope  may  not  be  needed  in  the  diagnosis  of  a  gross 
lesion  of  the  heart,  it  is  nevertheless  true  that  this  valuable  instru- 
ment will  enable  us  to  determine  and  localize  a  faint  cardiac  mur- 
mur quite  distinctly.  Likewise  though  the  diagnosis  of  a  fracture 
can  readily  be  made  by  a  number  of  clinical  and  pathognomonic  symp- 
toms, it  is  equally  true  tliat  the  roentgen  rays  and  the  fhioroscope  en- 
able us  in  many  cases  to  locate  exactly  tlie  direction  of  the  line  of 
fracture  and  to  determine  the  method  of  treatment,  appropriate  and 
beneficial  to  the  patient.  It  is  precisely  in  tlie  same  circumstances, 
but  with  a  still  greater  need,  that  the  urethroscope  enables  us  to 
localize  the  lesion  quite  exactly  at  a  particular  portion  of  the  urethra. 

The  scientific  mind  must  be  averse  to  instituting  a  method  of 

65 


PLATE  II 

Fig.   1. — Long  cel-slwpecl  polypus  on  the  anterior   aspect   of   the  verunK^n- 
tanum. 

Fig.   2. — Long   pliallus-shaped  polypus  on   the   apex   or   crest   of   the   veni- 
montanum. 


Fig.  1. 


Fig.  2. 

PLATE  II 


URETHROSCOPY  67 

therapy  ai;'ainst  a  j)a11i()l(),i;i('  ciilily  \\!ii('li  is  iiol  known  in  all  its  do- 
tails.  SiU'li  a  procedure  would  he  a  step  in  Ili«'  dark  and  Avouid  ])rac- 
lieally  rediiee  llie  treatment  oL'  uretliritis  to  an  empii'ieisni  wlncli  is 
no  longer  in  liarniony  with  the  present  time. 

The  nrctlii-al  walls  ai-c  not  visil)k;  naturally  and  only  the  gi'oss 
urethral  lesions  are  recognized  through  the  means  ordinarily  em- 
ployed. The  aim  of  urethroscopy,  however,  is  to  see  the  localized 
urethral  lesion,— to  know  its  exact  situation,  as  well  as  its  size  and 
shape.  By  this  method  of  investigation  we  are  enabled  to  ap])ly  to 
the  urethral  nmcosa  the  principle  of  all  rational  surgery;  namely,  to 
make  an  exact  diagnosis  of  the  urethral  lesions  by  looking  directly 
at  them  and  treating  them  subsequently  according  to  the  diagnosis 
thus  determined.  There  is  but  one  method  by  which  the  folds  and  re- 
cesses of  the  urethra  can  be  studied  and  that  is  by  looking  at  them 
directly  through  the  urethroscope.  This  instrument  better  than  any 
other  brings  to  view  the  chronic  foci  by  localizing  the  lesions  in  the 
urethra.  It  is  true,  of  course,  that  the  seat  of  the  lesions  in  the  ure- 
thra ma)^  be  determined  in  a  general  way  by  examination  of  the  urine 
and  its  shreds  passed  into  several  glasses,  but  this  method  does  not 
tell  us  in  which  i^articular  portion  of  the  urethra  the  foci  are  situattMl, 
nor  does  it  tell  us  anything  of  their  character. 

The  anterior  urethra  is  comparatively  long  and  the  methods  of 
treatment  applicable  to  its  lesions  vary  considerably,  and  the  instru- 
ments employed  also  differ  considerably  according  to  the  location  of 
the  infection.  Lesions  of  Littre's  glands  of  the  penile  urethra,  for 
example,  are  not  treated  in  the  same  manner  as  inflammations  situ- 
ated at  the  bulb.  And  how  can  one  be  sure  of  the  exact  location  if  the 
lesion  has  not  actually  been  seen  with  the  eye?  The  urethroscope  alone 
meets  this  demand.  And  we  may  add  that  besides  the  precision  in 
the  means  of  localization  which  urethroscopy  offers,  this  metliod  also 
affords  the  possibility  of  energetic  local  treatment  applied  directly  to 
the  lesions.  The  great  value  and  importance  of  this  method  of  ther- 
apy nuist  be  emphasized;  and  it  is  also  proper  to  indicate  how  il- 
logical it  would  be  to  attempt  the  treatment  of  a  surgical  lesion  with- 
out seeing  it. 

Lastly,  urethroscopy  enables  ns  to  note  clearly  and  precisely  tlu^ 
results  ol)tained  dui-ing  a  methodical  course  of  treatment.  In  ure- 
thral dilatation  for  sti-icture,  the  progrc^ss  of  th.e  case  can  hv  I'oHowimI 
step  by  step;  and  when  bleeding  takes  jilace,  we  can  not  only  locate 
the  tear,  but  also  determine  the  appropriate  intervals  for  dilatatu)n. 
As  a  matter  of  fact,  so  long  as  the  tear  caused  by  the  dilatation  is 
not  entirely  cicatrized,  repeated  dilatation  meiely  separates  the  ends 


68  CYSTOSCOPY   AND    URETHROSCOPY 

of  the  tear  without  serving  any  benefit  to  the  remainder  of  the  ure- 
thral circumference.  Beneficial  when  carried  on  prudently  under  the 
control  of  the  urethroscope,  dilatation  ma}^  be  of  no  actual  value  and 
even  disastrous  when  it  is  done  blindly. 

It  must  appear  after  all  that  has  just  been  said,  that  the  criti- 
cisms generally  aimed  at  urethroscopy  must  fall  of  their  OA\ai  weight. 
The  argument  so  often  made  that  urethroscopy  does  not  teach  us 
anything  that  we  can  not  learn  clinically,  does  not  seem  to  us  worthy 
of  consideration.  Just  one  glance  at  the  draAvings  which  we  publish 
will  suffice  to  indicate  how  the  mysterious  veil  thrown  over  the  eti- 
ology of  certain  refractory  urethritides  has  been  set  aside  by  the  use 
of  the  urethroscope,  and  it  also  explains  the  real  reason  for  the  check 
which  older  methods  of  treatment  have  received  since  its  use  has  be- 
come widespread. 

In  the  matter  of  accidents  which  may  result  from  urethroscopy^, 
such  as  eiDididymitis,  cystitis,  etc.,  they  mil  be  positivel}'  avoided  if 
the  proper  technic  is  employed  (see  page  74).  ITrethroscop}^  should, 
of  course,  never  be  emplo^^ed  in  the  diagnosis  of  lesions  which  are 
acute,  extensive,  or  recent;  it  should  be  utilized  onl}^  under  certain 
Avell-defined  conditions  which  are  specified  later  on;  and,  it  may  be 
added,  if  carried  out  with  pro^Der  precautions,  this  method  will  never 
give  rise  to  the  least  untoward  complication. 

Conclusion. — UretJiroscopy  must  he  accepted  as  a  routine  m-ethod 
of  urethral  exploration.  From  the  standpoint  of  diagnosis  it  furnishes 
informcition  infinitely  more  usefid  than  any  other  method  of  investiga- 
tion; and  from  the  therapeutic  point  of  vieiv  it  enables  the  practitioner 
to  act  precisely  as  ivell  as  effectively.  And  finally,  in  the  treatment  of 
chronic  urethritis  it  is  absolutely  indispenscible. 

Moreover,  when  endoscop^^  has  been  employed  for  some  time  in 
the  urethra  or  the  bladder,  and  when  the  operating  and  instrumental 
technic  have  been  fully  mastered,  it  is  difficult  to  conceive  why  this  val- 
uable aid  in  diagnosis  and  treatment  is  not  always  utilized.  Congested 
areas,  ecch^auoses,  soft  infiltrations  of  the  mucosa, — all  of  these  are 
beautifully  seen;  \n.i\\  patience  and  proper  equipment  one  can  enjoy 
the  sensation  of  actuall}^  doing  real  scientific  work,  both  surgical  as 
well  as  useful. 

The  Importance  of  Urethroscopy  in  Determining  the  Absolute  Cure 
of  Urethritis. — It  is  needless  to  insist  on  the  great  importance  of  de- 
termining whether  a  patient  is  or  is  not  completely  cured  of  his  ure- 
thritis. As  we  all  know,  this  is  a  matter  of  vital  interest,  for  it  may 
be  the  means  of  avoiding  terrible  and  even  fatal  consequences  in  the 
future.     Undoubtedly,  valuable  information  as  to  a  cure  can  be  de- 


URETHROSCOPY  .  69 

rived  from  a  cai-crul  cxainiiiatioii  ol'  the  iii-iiK;  wliicli  has  been  retained 
several  liours  and  a  study  of  tlic  rilainciits  A\liicli  it  contains.  Likc- 
mse,  massage  of  tlie  urethral  glands  and  the  exploration  of  the  ure- 
thral mucosa  stretched  upon  a  curved  Beniquc  sound  will  also  fur- 
nish most  valuahle  information.  Ijut  it  is  equally  true  that  surpris- 
ing relapses  often  occur,  notwithstanding  these  tests.  These  relapses 
often  can  not  be  explained. 

In  cases  Avhere  marriage  has  been  permitted  prematurely,  fatal 
consequences  may  ensue.  It  is  our  duty,  in  every  case  of  approach- 
ing marriage,  to  take  every  loossible  precaution  to  avoid  future  dis- 
aster. Among  these  precautions  the  most  important  is  the  minute 
examination  of  the  entire  urethral  mucosa  by  means  of  the  urethro- 
scope. For  it  is  only  through  this  medium  that  we  can  obtain  the 
most  detailed  and  exact  data,  in  order  to  determine  a  complete  cure 
and  thus  deliver  to  the  patient  his  "certificate  of  health"  wliicli  will 
enable  him  to  enter  the  marriage  state  in  complete  moral  and  physical 
security. 

it  may  he  safely  stated  that  the  perfect  and  sure  cure  of  a  ure- 
thritis shoidd  not  he  affirmed  ivithout  a  complete  and  minute  %ire- 
throscopic  examination  of  the  urethrcd  mucosa'  having  heen  made. 

Several  instances  mentioned  further  on,  in  Avhich  the  gonococcus 
has  persisted  in  the  urethra  over  a  period  of  many  years  Avithout 
arousing  suspicion,  Avill  demonstrate  the  absolute  necessity  of  ure- 
throscopic  control  before  marriage  is  permitted.  We  can  not  do  bet- 
ter than  to  recall  the  opinion  of  Oberlaender  and  Kollmann,^  on  this 
subject : 

"However  mild  the  case  under  observation  may  have  been,  one 
should  not  be  content  with  a  single  examination  in  forming  an  opinion 
as  to  a  cure;  to  the  contrary,  many  examinations  should  be  made,  not 
only  at  an  interval  of  several  days,  but  for  several  weeks  in  succes- 
sion, and  on  each  occasion,  the  urethroscope  must  be  employed,  the 
patient  not  having  urinated  for  five  or  six  hours.  Cocaine  must  not 
be  employed.  The  entire  canal  shoidd  be  examined  from  end  to  end. 
To  be  sure  that  tlie  cure  is  complete,  the  canal,  which  has  been  ex- 
amined, must  fulfill  these  conditions: 

"The  mucosa  nmst  present  noi'iiial  I'olds,  with  iicrfcct  longitu- 
<linal  ridges  or  furrows.  There  must  be  no  di1'f(U'euce  in  color  l)etween 
the  parts  originally  affected  and  those  which  remained  healthy.  Tlie 
epithelium  should  be  bright  throughout.  The  orifices  of  the  lacuna^ 
and  of  Littre's  glands  nuist  show  no  evidence  of  irritation,  and  tlie 
periglandular  infiltrations  and  the  cicatrices  of  the  deep-seated  glands 


70  CYSTOSCOPY   AND    UEETHEOSCOPY  ^ 

should  not  appear  at  the  mucous  surface,  but  should  present  a  healthy 
epithelial  surface  like  the  rest  of  the  canal. 

"Cicatrices  which  may  have  formed  beneath  the  epithelium  should 
be  no  longer  distinguishable,  but  should  be  covered  over  with  a  nor- 
mal epithelial  surface." 

Indeed  Avhen  it  is  a  matter  involving  so  grave  a  responsibility 
as  that  of  granting  permission  to  marry,  it  is  essential  that  every 
possible  precaution  should  be  taken,  and  Ave  can  not  fail  to  subscribe 
most  heartily  to  the  indications  laid  down  by  Ol^erlaender  and  Koll- 
mann.  But  it  is  true,  nevertheless,  that  in  many  instances  Ave  can 
not  possibl}^  hope  for  a  complete  restitutio  ad  integrum.  This  is  nota- 
bly true,  for  example,  in  the  case  of  strictures. 

As  soon  as  ^ve  are  assured  that  there  is  no  further  possible  con- 
tamination from  the  gonococcus  or  other  organisms,  and  Avlien  this 
decision  has  been  arriA^ed  at  by  the  faithful  use  of  the  urethroscope, 
Ave  may  AAdth  reasonable  assurance  declare  that  there  no  longer  ex- 
ists any  germ  focus  and  that  the  proposed  marriage  may  then  be 
sanctioned. 

EEFEPvEE-CE 
iQlaerlaender  uud  Kollmann :     Die  clironisclio  Goiionhoe,  Leipzig,  1901,  p.  168. 

TECHNIC  OF  URETHROSCOPY 

Preparation  of  the  Instruments. — The  examining  table  should  be 
eleA^ated,  and  AvheneA^er  possible,  proAdded  Avith  an  adjustable  back. 
Footrests  or  stirrups  are  attached  to  the  front  legs  (Fig.  45).  The 
instrument  is  made  ready  and  tested,  after  having  taken  pro|)er  care 
to  insure  perfect  Avorking  of  the  instrument,  connecting  Avires,  etc. 
The  source  of  light  for  the  small  electric  lamp  A^aries.  The  light  is 
usually  derived  from  the  city  electric  current  by  means  of  a  rheostat, 
Avhich  regulates  at  AAill  the  amount  of  current  in  the  lamp.  The  models 
of  Heller  (Fig.  46),  Gaiffe  (Fig.  47),  T.oeAvenstein  (Fig.  48)  and  of 
Leiter  are  most  frequently  emiDloyed,  In  America,  a  "transformer" 
knoAvn  as  a  "controller"  or  rheostat  is  generall}^  used  (Fig.  49).  This 
regulates  the  tension  of  the  current  from  zero  up  to  25  A^olts;  it  is 
X)ractical  and  inexpensive. 

When  the  city  current  is  not  available,  a  dry  battery  may  be  used. 
True,  it  is  short-liA^ed,  but  it  is  easil}^  reneAved  (Fig.  50).  Because  of 
their  small  size  the}^  are  easily  carried  about  in  the  pocket;  but  their 
short  life  is  a  decided  disadvantage.  An  electric  turbine  maA^  also 
be  employed,  proAdded  Avater  under  pressure  is  aA^ailable,  to  make 


TECIINIC    OF    URETiniOSCOPY 


71 


tlic  turbino  rotate.  The  electric  turbine  consists  of  a  dynamo  with  a 
magnet,  upon  the  axis  of  which  is  provided  a  large  aluminmn  ring. 
The  inner  surface  of  this  ring  is  corrugated;  two  powerful  jets  of 
water  falling  oliliquely  and  proceeding  from  two  pipes  placed  one 
opposite  the  other,  cause  the  rotation  of  the  magnets  and  thereby 
produce  the  current. 

Sigurta,  of  Milan,^  has  devised  a  very  interesting  method  which 
can  render  great  service  w^hen  electricity  can  not  be  had.  This  appa- 
ratus (Fig.  51)  is  made  up  of  a  small  dynamo,  the  action  of  which 


Fig.   45. — Urethroscopic    examining   table    (author's    model). 

is  produced  by  a  flying  gear,  which  is  set  in  motion  by  the  hand  of  an 
assistant.  The  rapidity  of  the  movements  transmitted  to  the  dynamo 
determines  the  intensity  of  the  current  and  the  voltage  of  the  lamp. 
A  very  sensitive  indicator  regulates  the  current  employed. 

The  source  of  light  having  been  provided,  the  handle  of  the  ure- 
throscope with  its  lamp,  is  connected  with  a  cal)le  to  the  rheostat  and 
the  current  is  turned  on  gradually  until  a  white  light  is  obtained  in 
the  lamp.  The  urethroscopic  tubes  are  selected  according  to  the  in- 
dividual case.    If  the  anterior  urethra  is  to  be  examined,  a  short  7  cm. 


72 


CYSTOSCOPY    AXD    USETHEOSCOPY 


Fig.  46. — Rheostat  for   light   and   cautery   adapted   for   city   current    (Heller). 

tube  is  to  be  jDref erred,  for  a  clearer  view  is  tliiis  produced.  If,  on 
the  contrary,  tlie  entire  nretlira  is  to  be  studied,  the  long  13  cm.  tube 
should  be  selected.     For  the  posterior  urethra  and  prostatic  lesions 


Fig.    47. — Rheostat   for  light   and   cautery,   using  city   current    (Gaifie). 


TECHNIC    OF    URETHROSCOPY 


73 


(veru)  particularly,  tlic  longer  14  cm,  tiihc  Avill  give  the  best  results. 
It  goes  without  saying  that  each  of  these  various  sized  tubes  is  pro- 


Fig.  48. — RTieostat   for   light,    using   city   current    (Loewenstein). 

vided  Avith  a  lamp  carrier  of  corresponding  length.     The  caliber  of 
the  tube  most  connnonly  used  is  24  or  26,  and  even  28  French,  if  it 


l^^\  \ 


Fig.   49. — Light   controller. 


Fig.  50. — Pocket  battery. 


Avill  pass  the  meatus.    The  magnifying  lens  corresponding  to  the  focal 
length  of  the  tube  is  now  adjusted  to  the  handle. 


74 


CYSTOSCOPY    AND    UEETHEOSCOPY 


The  special  instruments  required  for  the  local  treatment  of  the 
urethral  lesions  are  placed  on  a  table  to  the  right  of  the  operator,  so 
that  the  diagnosis  may  be  made  and  the  treatment  applied  at  the  same 


Fig.    51. — Sigurta's   portable    batter}^    for    electric    illumination. 

sitting.  These  instruments  are  the  following:  AVooden  cotton  car- 
riers or  applicators,  both  ends  capped  Avith  cotton  (Fig.  52) ;  a  pair 
of  long  forceps,  designed  for  the  recovery  of  cotton  which  may  drop 


Fig.   52. — Wooden    cotton    carrier. 


from  the  applicator;  a  tine  wire  cautery  and  a  Kollmann  electrolytic 
needle.    The  tubes  and  their  obturators  are  sterilized  by  boiling. 

Preparation   of  the  Patient. — The  lower  garments   are  removed 


Fig.    53. — Special   forceps   for   intraurethral   work. 


and  the  feet  and  legs  encased  in  operating  stockings.     The  bladder 
should  be  full  preferably.     The  patient  lies  on  his  back,  the  feet  rest- 


TECHNIC    OF   URETHROSCOPY 


ro 


ing  in  the  stirrups,  the  buttocks  drawm  Avell  forward  to  the  edge  of 
the  table  (Figs.  54  and  55).  For  the  posterior  urethra  alone,  the 
lithotomy  position  is  to  be  preferred.     The  patient  and  instruments 


Fig.   54.— Examination  of  the  anterior   urethra;   showing  position  of  operator  and   patient. 


Fig.   SS.-Examination   of   the  posterior   urethra;   showing  position   of   operator  and   patient. 

thus  prepared,  the  glans  and  the  meatus  are  cleansed  with  a  mild 
antiseptic  solution. 


76 


CYSTOSCOPY   AXD   UEETHEOSCOPY 


Examination  of  the  Posterior  Urethra. — Previous  to  the  urethro- 
scopic  examination,  it  mnst  be  deteniiined  that  tlie  meatus  is  large 
enough  to  admit  the  passage  of  the  uretliroscopic  tube,  and  that  there 
is  no  stricture  in  the  urethra  of  a  caliber  sufficiently  small  to  obstruct 
the  tube.  In  the  normal  urethra,  the  meatus  constitutes  the  narrow- 
est portion  of  the  canal;  it  may,  therefore,  be  necessary  to  perform 


Fig.   56. — Ten   c.c.    syringe,    for   intraurethral   injection    of   cocaine    or   stovaine;    can   be   boiled. 


meatotomy  if  the  meatus  is   too   small  to  permit  the  passage  of  a 
uretliroscopic  tube  Avithout  x)ain. 

Unless  there  are  special  indications,  it  is  advisable  that  nothing 
be  injected  into  the  urethra  before  the  examination,  in  order  that  any 
retained  glandular  or  other  secretions  shall  remain  for  observation 
and  study.    ^Mien  the  examhiation  is  comiDlete,  the  urethra  is  washed 


Introduction   of   the   iiretbroscopic   tube   into    the  posterior   urethra. 


out  thoroughly  by  the  x)atient  voiding  the  urine  in  the  natural  manner. 
Occasionally,  in  sensitive  or  nervous  patients,  it  Avill  be  necessary 
to  anesthetize  the  urethral  mucosa.  This  is  best  done  by  injecting 
into  the  anterior  urethra  8  to  10  c.c.  of  a  1  per  cent  solution  of  stovaine 
with  a  syringe  (Fig.  56).     But  this  should  be  avoided  so  far  as  pos- 


TECHNIC    OF    URETHROSCOPY 


i  i 


siblc,  as  stovaino  causes  an  aiicinia  of  ihc  iirdln-al  iiiuffjsa  Avliicli  alters 
the  uretliroseopic  picture  iiiateiially.  [In  America  stovaine  is  not  re- 
garded favorably  for  local  anesthesia.  Alypin  2  per  cent  is  not  toxic 
and  does  not  lilancli  the  mucosa.  For  the  anterior  urethra,  one  dram 
of  the  solution  is  injected,  and  retained  for  about  five  minutes,  when 
perfect  anesthesia  is  ol)tained.  For  the  deep  urethra,  two  or  three 
%  grain  tal)lets  deposited  by  means  of  a  Bransford  Lewis  tablet  de- 
positor, will  give  most  satisfactory  anesthesia. — Editor.] 


Fig.   58. — The    uretliroseopic    tulie    having    iieen    introduced,    the    obturator    is   withdrawn    and    the    handle    is 
attached   to   the   collar   of   the   tube    '.lamp   pointing   downward). 

Operative  Technic. — The  uretliroseopic  tube  and  its  ol)turator, 
having  been  selected  for  the  particular  case,  is  sterilized  and  freely 
lubricated  with  sterile  glycerin  or  jelly.  The  former,  being  trans- 
parent, has  the  advantage  of  affording  a  clear  unobstructed  yiqw  of 
the  urethral  mucosa.  The  tube  is  gently  introduced  down  to  the  mem- 
branous urethra;  its  passage  lieyond  this  point  is  facilitated  by  mak- 
ing pressure  Avith  one  liaiid  over  the  liy))()gastriuin,  thereby  lowering 
the  subpubic  ligaments. 

Tlie  introduction  of  the  straight  uretliroseopic  tube  into  the  pos- 
terior urethra  has  been  reerarded  bv  some  as  difficult;  some  writers 


78 


CYSTOSCOPY   AND    URETHROSCOPY 


have  even  insisted  on  preceding  the  introdnetion  of  the  tube  by  the 
passage  of  an  armed  filiform  guide.  But  this  is  really  unnecessary 
in  the  vast  majority  of  cases.  In  point  of  fact,  it  is  agreed  that  intro- 
duction of  the  tube  shall  not  be  attempted  unless  the  canal  is  suffi- 
ciently large  to  accept  it,  for  as  has  already  been  pointed  out,  urethros- 
copy is  useful  and  worth  while  only  under  this  condition. 

On  the  other  hand,  the  ]Dosition  of  the  XDatient  is  important.  He 
should  lie  on  his  back,  the  buttocks  resting  on  the  edge  of  the  table, 
and  his  feet  resting  in  the  stirrups.  The  operator  seating  himself 
between  the  patient's  legs,  slowly  passes  the  instrument  vertically  into 
the  urethia.    AVhen  the  tip  has  reached  the  membranous  urethra,  the 


Fig.  59. — In  the  examination  of  the  posterior  urethra,  the  handle  of  the  urethroscope  is  turned 
upward,  the  lamp  also  upward,  to  avoid  the  urethral  secretions  which  gravitate  down  upon  the  lower  wall 
of  the  tube. 

handle  is  depressed  so  that  the  tube  lies  horizontally,  and  with  a  little 
dexterity  it  passes  easily  into  the  deep  urethra  (Fig.  57).  When  all 
resistance  has  ceased  and  the-4;ube  moves  freely,  we  know  that  it  has 
entered  the  bladder ;  further  evidence  is  offered  by  the  escape  of  urine 
through  the  tube. 

The  tube  is  now  drawn  forward  gradually  until  the  flow  of  urine 
ceases.  The  tip  of  the  instrument  is  now  in  the  deep  urethra.  The 
secretions  of  this  part  of  the  canal  are  now  swal)bed  with  the  cotton 
carrier  and  when  the  mucosa  is  fairty  dry,  the  lamp  is  inserted  (Fig. 
58)  with  the  handle  of  the  urethroscope  pointing  downwards.  The  tube 
is  now  rotated  180  degrees,  so  that  the  lamp  rests  on  the  upper  sur- 


TECHNKi  ()|.'   nr.K/i'ii  Koscoi'N' 


'!) 


I'ac*'  of  llic  tiilx'.  Ill  lliis  way,  llic  laiii|)  Is  inaiiilaiiMMl  lii^li  alioNc  l!ic 
urclliral  floor,  g'iviiiii,'  a  heller  illiiiiiinalioii,  and  it  is  kepi  I'lom  heijii;' 
ohscuTod  coiitimuilly  ])y  (lie  secrelioiis  on  llie  nrellnal  lloor  wliieli 
should  1)0  studied  carofully,  aud  which  would  he  eiicounlenMl  were 
the  lamp  not  I'otatod  iu  this  manner. 

Tho  vorumontanum  is  visible  below  and  can  easily  be  freed  from 
accmnulated  secretions  or  blood  by  the  cotton  swal).  This  assures  a 
clear  and  distinct  view.  Little  by  little  the  tube  is  di-awn  forward 
and  all  portions   of  the  canal  thus  br()U.L!,'lit  under   inspeelion   of  ilie 


Fig.   60. — Intraurctliral    niani]]iiIatioii ;    drying    tlie    imicnsa    wiili    cotton    swabs. 

observer.  The  urethral  mucosa  can  be  distinctly  iiisi)ected  willi  vo- 
markable  clearness  by  this  method,  owing-  to  the  clennsiuu-  \\itli  I  he 
cotton  SAvab. 

In  the  older  ui-ethroscopes  with  inteiaial  light,  siicli  as  the  Ober- 
laender,  for  exani])le,  it  was  necessary  to  wit  lid  raw  the  light  each 
time  before  the  applicator  could  bo  insiMied;  willi  this  iiist lument, 
however,  tho  lamp  may  not  only  remain  in  its  place  witliiuit  cansiug 
any  iuconveuieuce,  l)ut  in  addition,  it  serves  to  aid  and  ilhiminale  \\\o 
necessary  manipulation  in  the  intei-ioi-  of  the  tnhe.  it  is,  therel'ore,  a 
simple  matter  to  apply  caustics  aud  other  theiapeiitic  agents  directly 
to  the  affected  spot,  owing  to  tiie  direct  \iew  thus  ohtainod  (Fig.  GO). 


PLATE  III 

Fig.  1. — Glandular  lesions  of  the  anterior  wall  of  the  prostatic  urethra,  as 
seen  through  the  urethroscope.  All  the  infected  glands  of  the  prostate 
are  seen  vesiculated  and  have  the  appearance  of  frog's  spawn.  Under 
dilatation,  all  the  prostatic  vesicles  burst  and  disappeared,  and  a 
cure  resulted. 

Fig.  2. — Glandular  lesion  of  the  anterior  surface  of  the  prostate,  seen 
through  the  urethroscope.  Compare  this  picture  -with  Fig.  1,  Plate  I, 
which  represents  the  healthy  condition. 


Fig.  1. 


Fig.  2. 

PLATE  III 


TECTTNIC    OV    riiKTI  lltOSCOPY  81 

Contraindications  to  Urethroscopy. — Uretliroscopic  examinations 
slionld  not  ])e  made  rocklossly  in  all  cases  of  urethritis;  in  acute  or 
recent  infections  the  introduction  of  any  instrument  in  an  inflamed 
canal  must  be  prohibited.  This  instrument  may,  therefore,  be  em- 
ployed only  wIkmi  there  is  no  pain  on  urination,  or  during  erections, 
and  when  the  urine  is  fairly  clear.  Nor  should  the  examination  be 
made  while  the  urethra  is  still  sensitive  or  tender. 

Generally  speaking,  the  uretliroscopic  tube  should  never  he  used 
unless  we  are  familiar  ivith  the  urethral  caliber.  It  is  extremely  un- 
wise to  insert  a  urethroscoi^ic  tube  into  a  patient  who  has  been  seen 
for  the  first  time.  There  is  always  the  risk  of  being  stopped  by  a 
small  meatus  or  a  stricture  in  the  urethra,  with  the  resulting  pain  and 
hemorrhage.  Urethroscopy  should  also  not  be  undertaken  ivhile  there 
are  inflammator}^  complications  of  the  posterior  urethra,  such  as  epi- 
didymitis, acute  prostatitis,  etc.  Finally,  as  an  axiom,  the  uretliro- 
scope  shoidd  never  he  employed  in  a  caned  which  has  not  heen  pre- 
viously studied  and  dUated. 

Concerning  Adrenalin  in  Urethroscopy. — This  is  a  valuable  aid  in 
urethroscopy,  in  cases  in  which  there  is  an  oozing  of  blood  ^\'hieh 
renders  the  examination  of  a  particular  spot  almost  impossible.  Swab- 
bing with  cotton  is  of  no  avail,  owing  to  the  persistence  of  the  oozing, 
and  it  may  even  increase  the  bleeding,  in  some  instances.  The  em- 
ployment of  adrenalin  in  these  circumstances  is  strongly  indicated. 
A  cotton  swab  dipped  in  a  1:10,000  solution  applied  to  the  bleeding- 
spot  will  quickly  stop  the  oozing.  But  the  surgical  principle  of  hemo- 
stasis  must  be  applied;  that  is,  the  exact  bleeding  point  must  be  iso- 
lated and  treated  with  the  solution.  If  the  adrenalin  is  applied  in 
haphazard  fashion,  it  will  probably  be  of  little  or  no  avail  Avhatever. 

There  is  a  decided  disadvantage  in  using  this  medium,  however; 
while  adrenalin  is  a  vasoconstrictor  of  a  high  order,  a  vasodilatation 
is  produced  just  as  soon  as  its  ephemeral  action  has  passed  off, 
and  this  is  capable  of  producing  a  secondary  hemorrhage  of  an  ex- 
tremely disagreeable  character.  On  the  other  hand,  this  solution  must 
be  used  only  drop  by  drop,  and  should  never  be  injected  into  the 
urethra  with  a  syringe.  Johnson,  of  San  Francisco,'  reported  a  case 
in  this  connection  in  Avliich  hemorrhage  followed  a  urethral  dilatation, 
Johnson  endeavored  to  stop  the  bleeding  by  filling  the  anterior  urethra 
with  a  1:4,000  solution  of  clilorhydrate  of  adi'ciialin.  The  i>aticiit  siid- 
denh^  became  livid  and  motionless  and  his  eyes  became  glassy;  this 
was  followed  by  vomiting  and  complete  collapse,  feeble  respiration, 
pulse  hardly  percepti1)le  and  the  heartbeat  inaudible.  After  a  fcAV 
minutes  the  patient  was  revived  wiili   diriiculty  through  the  use   of 


82  CYSTOSCOPY   AND   URETHROSCOPY 

strong  hypodermic  stimulant   injections.     For   three   honrs   he   was 
nnable  to  stand  on  his  feet. 

REPEREIsrCES 

iSigurta:  Di  uu  nuovo  appareechio  portatile  indepeudente  per  la  produzione  della  luce  el- 
letriea  per  uso  endoscopieo,  Atti  della  Societa  Milanese  di  Mediciiia  e  Biologia,  Milano, 
1908,  iii,  No.   5. 

2johnsou:     Jour.  Am.  Med.  Assn.,  Oct.  7,  1905,  p.  1086. 


URETHROSCOPY  OF  THE  NORMAL  AND  PATHOLOGIC 

URETHRA 

1.  Urethroscopy  of  the  Normal  Urethra 

General  Observations.— Before  entering  on  a  stndy  of  the  nrethra, 
it  is  well  to  consider  a  few  observations  common  to  all  portions  of  the 
canal.  The  consistency  or  thickness  of  the  mucosa  varies  according 
to  the  individual  to  be  examined.  It  is  thinner  and  more  delicate  in 
individuals  whose  genital  organs  are  small  or  atrophied ;  while,  on  the 
other  hand,  it  is  firmer  and  denser  in  vigorous  subjects.  The  color  of 
the  mucosa  also  varies  considerably  in  different  individuals,  ranging 
in  the  normal  state  from  a  reddish  gray  to  blood  red,  according  to 
the  extent  of  vascularization. 

The  color  differs  also  according  to  the  caliber  of  tube  employed. 
If  a  large  tube  is  used,  the  pressure  which  it  exerts  on  the  mucosa  is 
often  sufficient  to  produce  a  distinct  anemia  and  blanching  of  the 
mucosa.  If  the  operator  makes  more  or  less  pressure  on  one  wall,  he 
causes  a  localized  paleness  on  that  spot,  which  an  inexperienced  ob- 
server might  regard  as  pathologic;  but  by  moving  the  tube  it  is 
readily  seen  that  the  change  in  color  is  due  only  to  the  pressure  of  the 
tube  on  the  wall.  The  local  use  of  cocaine  or  stovaine  will  also  jDroduce 
an  anemia  of  the  mucosa. 

A  rather  extensive  experience  in  urethroscopy  permits  me  to  note 
a  rather  interesting  phenomenon ;  namel}^,  that  the  color  of  the  mucosa 
seems  to  correspond  with  that  of  the  face  of  the  patient.  Very  often 
in  the  course  of  a  urethroscopic  examination  when  I  noticed  that  the 
urethral  mucosa  suddenly  became  white,  I  observed  that  the  patient's 
face  became  white  at  the  same  time  and  that  he  was  about  to  faint. 

Two  distinct  features  of  importance  ma^^  be  distinguished  in  every 
urethroscopic  picture;  i.e.,  the  "central  figure,"  and  the  mucous  sur- 
face proper.  The  central  orifice  of  the  urethral  canal  constitutes  the 
"central  figure."  Normally,  the  urethral  walls  are  in  apposition,  so 
that  its  lumen  is  potential  rather  than  real  except  while  urine  is  pass- 


IJRETTinOSCOP^'    OF    XORMAL    AND    PATirOLOOIC    URETHRA  Ki 

iiii;-  tlii'()ii,<;ii.  When  tlic  cikIoscojx'  is  iiisci'icd,  li()\\('V<'i',  tii(;  urothral 
walls  separate  symmetrically  at  the  lower  end  ol'  the  instrument, 
presenting  an  appearance  resenililing  a  Funnel,  tin;  neck  of  which  is 
made  up  of  the  center  of  the  ui-etliral  canal  and  the  sides  are  formed 
by  the  walls  of  the  urethra  prox:)er. 

This  funnel  is  more  or  less  distinctly  defined  according  to  the 
position  in  which  the  urethroscopic  tube  is  held.  AVhen  the  hold  on  the 
tube  is  relaxed  the  funnel  effect  is  l)ut  slighth^  visil)le;  and  when  tlie 
tube  is  iDushed  downward  against  the  pressure  of  the  hand,  the  mucosa 
is  drawn  or  pushed  into  the  lumen  of  the  tube  and  the  funnel  sliape 
becomes  still  less  marked  and  almost  done  away  with  entirely.  But 
when  the  tube  is  drawn  forward  toward  the  meatus,  the  funnel  be- 
comes deeper  and  better  defined,  and  if  in  addition,  pressure  is  made 
on  the  penile  urethra  with  the  free  hand,  a  very  long  funnel  will  be 
created  which  may  even  assume  the  appearance  of  a  true  cylinder. 

There  is  a  decided  advantage  in  each  of  these  methods  of  examin- 
ing the  urethra.  In  point  of  fact,  when  the  mucosa  in  the  tube  is  made 
to  stand  out  prominently  by  pushing  the  tube  downward,  certain  local- 
ized areas  may  be  examined  with  great  clearness ;  when,  on  the  other 
hand,  however,  traction  is  made  on  the  penis  and  on  the  urethroscope 
simultaneously,  the  lesions  may  be  observed  in  profile.  This  method 
of  examination  is  of  consideral)le  value  when  the  purpose  of  tlie  exam- 
ination is  to  discover  small  chronic  glandular  inflammations  which  i3ro- 
ject  slightly  into  the  lumen  of  the  urethra. 

In  order  to  see  everything  Avell,  it  is  essential  that  all  of  these 
variations  must  be  known  to  the  observer.  Similarly  when  a  par- 
ticular spot  is  to  be  examined  carefully,  the  tube  may  l^e  inclined  on  the 
axis  of  the  urethra  and  an  eccentric  view  may  be  obtained,  if  the  cen- 
tral figure  is  still  visible ;  but  if  the  central  figure  has  comxDletely  dis- 
appeared, onl}^  the  urethral  walls  Avill  be  seen. 

The  aspect  of  this  central  figure  varies  considerably  in  different 
portions  of  the  urethra.  At  the  glans,  it  has  the  form  of  a  little  oval 
slit;  in  the  penile  region,  it  resembles  a  point;  in  the  bulbous  portion, 
it  takes  the  appearance  of  a  vertical  slit ;  and  finally,  in  the  deep  urethra, 
at  the  level  of  the  verumontanum,  it  assumes  a  peculiar  aspect  due  to 
the  prominence  of  the  verumontamim  (Plate  I,  Figs.  2,  3,  and  4). 

The  surface  of  the  urethral  mucosa  presents  a  series  of  longitu- 
dinal folds  or  striations  in  the  shape  of  wheel  spokes.  These  folds  are 
more  or  less  marked  according  to  tlic  degree  of  stretching  of  the  ure- 
thra and  also  according  to  the  thickness  of  the  tube  employed.  Tn  the 
normal  uretln-a  they  are  quite  well  marked,  but  they  undergo  consider- 
able modification  in  pathologic  conditions. 


84  CYSTOSCOPY  a:n^d  tjretheoscopy 

In  the  normal  mucosa  the  color  of  these  striations  is  a  more  or  less 
Ihdcl  red,  the  striations  forming  heantiful  bright  red  ra^^s  which  merge 
gradually  into  the  substance  of  the  mucosa,  which  is  of  a  light  3^ellow 
rose  color.  The  surface  of  the  normal  mucosa  is  smooth  and  brilliant 
throughout  and  it  becomes  irregular  and  dull  in  the  XDathologic  state. 

The  orifices  of  the  lacunae  of  Morgagni  are  barely  \dsible  in  the 
normal  urethra ;  when  visible,  they  appear  in  the  form  of  little  points  or 
needle  pricks  slightly  dilated,  and  are  situated  on  the  upper  wall  of 
the  urethra.  Likewise,  the  glands  of  Littre  are  practically  invisible  in 
the  healthy  urethra,  and  often  are  passed  unnoticed  in  an  examination 
of  the  canal.  We  shall  see  later  on,  however,  that  they  change  mate- 
rially rmcler  loathologic  influences ;  they  become  protruding,  and  con- 
gested, surrounded  by  a  reddish  zone,  and  easily  visible. 

2.  Urethroscopy  of  the  Normal  Anterior  Urethra 

The  central  figure  is  practically  the  same  in  the  entire  anterior 
urethra,  except  that  at  the  gians  it  has  the  form  of  a  perpendicular  slit, 
sometimes  oval.  In  the  pendulous  portion,  it  has  the  appearance  of  a 
IDoint,  which  often  becomes  enlarged  and  takes  on  the  appearance  of  a 
transverse  cleft  studded  with  little  indentations.  The  longitudinal  folds 
ax)pear  like  the  s^Dokes  of  a  wheel.  They  are  more  easily  visible  if  a 
narrow  tube  is  employed  and  less  readily  recognized  when  a  thick  tube 
is  used.  In  the  region  of  the  glans,  where  the  urethral  mucosa  is 
smooth,  they  are  not  seen ;  they  vary  from  four  to  six  in  number. 

Longitudinal  striation  due  to  vascular  ramifications  is  more 
marked  in  vigorous  subjects.  The  lacunji?^  of  Morgagni  are  situated  on 
the  upper  wall  of  the  iDenile  region.  Their  orifices  look  like  little  pits 
having  a  color  similar  to  that  of  the  adjacent  mucosa.  Normally,  their 
walls  are  not  elevated  above  the  neighboring  mucosa.  The  large  lacu- 
nae, however,  are  easily  recogniza1:)le,  from  the  fact  that  they  are  V- 
shaiDed,  the  apex  of  the  letter  pointing  do^\mward  and  the  arms  bound- 
ing the  walls  of  the  follicle  (Plate  VIII,  Fig.  2). 

Littre 's  glands  exist  in  great  numbers  on  the  entire  surface  of  the 
urethra.  Normally  they  are  not  visible  and  become  so  only  patholog- 
ically. Cowper's  glands  ox)en  on  the  urethral  mucosa  through  orifices 
which  are  rarely  recognizable.  Most  often,  they  are  obscured  by  the 
folds  of  the  urethral  mucosa. 

3.  Urethroscopy  of  the  Normal  Posterior  Urethra 

The  tube  having  been  introduced  and  the  deep  urethra  cleansed 
mth  a  cotton  swab,  the  lam])  is  turned  on  and  a  distinctly  characteristic 


UPiETHIlOSCOPY    OF    NORMAL    AND    PATHOLOGIC    URETIIPiA 


85 


picture  is  o1)served  (Plato  I,  Fig.  1,  also  Fig.  Gl).    Abovo,  we  encoun- 
ter tlic  neck  of  tlio  bladder,  shaped  like  an  iiiruiidil)uluni  or  funnel. 


Fig.   61. — Urethroscopic   view   of   the   "prostatic   fosseltc."      Normal   aspect   of   the   posterior   urethra   situated 
between  the  verumontanum  and  the  neck  of  the  bladder. 

From  this  i)oint  the  folds  of  smooth  mucosa  descend  in  regular  and 
diverging  series  in  the  shape  of  a  fan.  The  handle  of  the  fan  is  above; 
the  body  of  the  fan  is  below. 


Fig.   62. — Anatomic    view    of    the    "prostatic    fossette,"    comprised    between     the    posterior    margin    of    the 

verumontanum  and   the   bladder   neck. 

Withdrawing  the  urethroscoiDe  gradually,  the  iDosterior  aspect  of 
the  verumontanum  comes  into  view.    Immediately  behind  the  verumon- 


86  CYSTOSCOPY    AXD    UEETHEOSCOPY 

tanum  is  a  little  fossette,  or  space,  wliicli  should  always  liave  a  tlior- 
ougli  examination.  This  prostatic  fossette  [postmontane  space — 
Editoe]  should  be  explored  methodically  in  cases  of  chronic  urethritis, 
for  it  is  very  often  the  seat  of  chronic  inflammations  Avhich  can  not  be 
seen  or  even  susioected  by  any  other  method  of  examination.  This 
space  is  well  shown  in  Fig,  62.     Anteriorly  it  is  bounded  by  the  idos- 


Fig.   63. — Xornial   verumontanum,    the   orifice   of   the   prostatic    utricle   not   visible. 

terior  wall  of  the  verumontanum;  posteriorly,  it  ends  at  the  bladder 
neck ;  laterally,  it  is  bounded  by  the  urethral  walls. 

It  has  been  maintained  that  this  examination  can  not  be  per- 
formed properly  with  a  straight  tube,  but  this  is  not  the  case,  for  it  is 
only  necessary  to  deiDress  the  extremity  of  the  tube  slightly,  seesaw 


Fig.   64. — Normal   verumontanum,    the    orifice    of    the    prostatic    utricle    visible. 

fashion  by  raising  the  handle  and  depressing  the  verumontanum.  In 
this  manner  the  posterior  wall  of  the  verumontanum  can  be  readily 
examined.  This  done,  the  tu]3e  is  gradually  and  gently  draA^^l  forward, 
thus  bringing  the  bod}^  of  the  verumontanum  into  view.  Its  usual 
appearance  is  well  shoA^ai  in  Plate  I,  Figs.  2,  3,  and  4. 


im;I'7I'iik()S('()|'\-  oi'    xoiimal  and   I'a  riioLodic   ri;i'7i"iii:A  87 

The  Verumontanum. Tlic  vci-uiiioiilaimin  usually  apjx'ars  in  the 
loriu  oL' a  spindle  ('l()iii;atc<l  froin  hd'oi-c  haekwafd  (  I^'ii;'.  (il^).  A1  limes 
it  takes  tlie  sliap*'  of  a  lai'.^c  pi-ojcclion  hui.^Iii.L;'  at  llic  lop;  a1  oilier 
times  it  fills  tlie  eiitir<'  luiucii  of  the  uid  liroscopic  tube;  occasionally 
only  the  anterior  as]i('('l  can  he  seen,  and  when  the  tube  is  di'awn  for- 
ward somewhat  further,  i1  is  seen  diminislie(|  in  liei.i;'ht  and  bi-eadth 
and  becomes  continuous  aiii<'i-iorly  with  ils  frenum.  Al  limes  llie  pros- 
tatic uti'icle  is  not  at  all  visible  (Fi^'.  ()3)  or  only  sliglitly  so;  while 
at  other  times  to  the  contrary,  it  is  clearly  perceptible  to  the  eye  (Fi^". 
64).  All  of  these  varied  aspects  are  beautifully  shown  in  the  colored 
plates. 

Tn  most  instances  the  prostatic  utricle  is  sin.<i,-le  and  situated  in 
the  median  line,  the  orifices  of  the  ejaculatory  ducts  remaininfi,-  invis- 


Fig.   65. — Normal   verumontanum,    without    a   median    prostatic    utricle;    the    ejaculatory    tlucts    terminate    lat- 
erally,   giving   the   appearance   of   a  diver's    helmet. 

ible;  but  in  many  cases  an  arrangement  quite  different  is  observed. 
The  utricle  is  not  seen  at  the  center,  but  the  ejaculatory  ducts  are 
clearly  visible,  each  orifice  corresponding  to  the  opening  of  an  ejacu- 
latory duct  situated  laterally  and  the  eiitiic  veiumontanum  closely  re- 
sembling a  diver's  helmet  (Fig.  05).  The  im})oi-taiice  of  the  examina- 
tion and  study  of  the  verumontanum  is  exceedingly  great  owing  to 
its  intimate  pathologic  relationship  with  the  seminal  vesicles.  This 
relationship  is  so  close  that  the  prostatic  utricle  well  deserves  the  title 
which  has  been  given  to  it;  i.  e.,  the  ''mirror  of  the  seminal  vesicles." 
Above  the  verumontanum  the  ])icture  changes  sud(h'nly.  The  ure- 
thral nmcosa  is  ai'ranged  in  folds  and  pi'eseiits  a  chai'acteristic  asjiect 
in  the  form  of  a  swelling  which  ()ccu])ies  the  entire  u])])e]-  ])art  oi*  the 


S8  CYSTOSCOPY    ASTD    UEETHEOSCOPY 

nrethroscox)ic  tube ;  it  forms  a  crescent,  concave  at  the  side,  avMcIi  sur- 
rounds the  verumontanum.  This  fold  is  a  very  vahiable  guide  in  esti- 
mating the  sliape  and  size  of  the  verumontanum.  ^ 

As  we  move  still  further  forward,  the  picture  changes  again.  The 
anterior  aspect  of  the  verumontanum  narrows  little  by  little  to  the 
Avidtli  of  its  frenum  and  completely  disappears  in  the  floor  of  the  ure- 
thra. "We  now  reach  the  membranous  urethra.  The  regular  schematic 
appearance  of  this  part  of  the  canal  presents  a  central  point  which  is 
the  lumen  of  the  urethra  and  from  which  the  striations  radiate.  As 
the  tube  reaches  this  portion  of  the  canal,  it  is  tightly  gripped  and 
moved  about  with  some  resistance,  but  as  it  is  brought  still  further 
anteriorly  the  resistance  diminishes  and  the  tube  moves  more  freely 
again. 

It  is  advisable  to  raise  the  handle  of  the  tube  gently  as  it  leaves 
the  membranous  urethra,  otherwise  there  is  danger  of  the  tube  being 
throA\m  ui^ward  suddenly  by  muscular  action,  thereby  causing  the 
patient  unnecessary  pain.  The  observer  now  passes  from  the  position 
indicated  in  Fig.  55  to  that  sho^^m  in  Fig.  54. 

The  vast  difference  in  the  urethroscopic  picture  is  now  noted. 
The  bulbous  urethra  gives  its  characteristic  aspect.  We  see  a  vertical 
cleft  very  distinctly  outlined.  On  either  side  are  two  smooth  muscular 
projections  diverging  outward.  This  ]3eculiar  vertical  slit  is  produced 
by  the  lateral  compression  exerted  at  this  point  by  the  bulbous  and 
ischiocavernous  muscles. 

4.  Urethroscopy  of  the  Pathologic  Anterior  Urethra 

General  Observations. — The  lesions  of  chronic  urethritis  viewed 
through  the  urethroscope  were  first  described  in  a  masterful  manner 
in  1893  by  Oberlaender,  and  in  a  later  work  in  collaboration  with  Koll- 
mann^  published  in  1910.  We  may  also  note  the  important  works  of 
De  Keersmaecker  and  Yerhoogen,'  of  AVossidlo,^  and  finally  in  France, 
of  Janet*  and  of  Fraisse.^ 

Oberlaender  following  the  evolution  of  the  gonorrheal  process  dis- 
tinguished two  distinct  factors  in  the  study  of  the  chronic  inflanmiatory 
lesions  of  chronic  urethritis.  The  first  is  the  soft  infiltration  {infiltra- 
tion molle)  characterized  macroscopically  by  a  turgescence  of  the  mu- 
cosa and  histological!}^  by  an  infiltration  of  the  submucosa  ^^ith  small 
cells,  the  entire  process  being  accompanied  by  vascular  dilatation. 

The  second  factor  which  succeeds  the  first  in  the  evolution  of  the 
pathologic  process  is  the  hard  infiltration  [infiltration  dura),  which  is 
characterized  macroscopically  by  a  special  paleness  of  the  mucosa, 
which  takes  on  a  yellowish  gray  color,  and  liistologicallv  bv  the  invasion 


URETHROSCOPY    OF    NORMAL    AND    rATHOLOGIC    URETHRA  89 

of  tlio  sul)inncosa  by  small  ooiinoctivc  tissuo  colls  -which  .i^radually  take 
the  place  oi"  the  enibryoiiic  cells  of  sol't  iiifilti'ation  and  eventually 
transform  the  submncosa  into  iibi-ous  tissue.  The  presence  of  this 
fibrous  tissue  strangles  the  blood  vessels,  stops  the  circulation,  and 
brings  about  this  particular  discoloration  of  the  mucosa. 

The  mildest  degree  of  this  type  of  infiltration  corresponds  to  the 
large  caliber  stricture  described  by  Otis,  -while  the  severest  degree  con- 
stitutes the  true  organic  stricture  of  the  urethra. 

Soft  infiltration  accompanies  and  follows  the  inflammatory  lesions 
of  acute  urethritis  and  is,  therefore,  found  chiefly  in  the  early  periods 
of  chronic  urethritis.  As  a  result  through  the  evolution  of  the  inflam- 
matory process,  the  soft  infiltration  is  eventually  replaced  by  hard 
infiltration.  Though  there  is  no  doubt  that  both  forms  are  absolutely 
dissimilar,  not  only  nrethroscopically  but  also  anatomically,  they  must 
in  fact  be  regarded  as  successive  phases  of  one  and  the  same  morbid 
evolution.  Moreover,  it  is  well  to  remember  that  both  types  can  exist  in 
the  same  urethra  simultaneously. 

It  is  Avell  laio-wn  that  chronic  urethritis  is  peculiarly  characterized 
by  the  presence  of  distinctl\^  localized  areas  of  chronic  inflammation. 
Each  of  these  morbid  processes  can  develop  locally  in  an  isolated 
fashion  by  itself.  So  that  in  a  given  urethra  it  is  quite  customary  to 
see  healthy  mucosa  alternate  with  portions  attacked  with  soft  infiltra- 
tion and  even  -with  hard  infiltration,  as  well. 

Before  taking  up  these  urethral  lesions,  it  is  well  to  point  out  the 
most  frecjuent  i)oints  of  localization  of  chronic  urethritis ;  i.  e.,  the 
middle  portion  of  the  penile  urethra,  the  penoscrotal  angle,  and  the 
membranous  region.  Indeed,  several  distinct  areas  may  be  involved  at 
the  same  time. 

Soft  Infiltration. — There  is  no  particular  difficulty  in  introducing 
the  urethroscope  into  a  canal  affected  with  soft  infiltration  only.  At 
most  the  urethra  may  bleed  slightly  either  during  the  passage  of  the  in- 
strument or  while  the  lesion  is  being  swabbed  Avith  cotton.  The  general 
appearance  presented  by  the  urethra  affected  with  soft  infiltration  is 
that  of  a  hyperemic  mucosa,  inflamed  and  turgid.  Usually  it  is  smooth 
and  glistening  (Plate  VII,  Fig.  5).  It  is  best  compared,  for  purpose 
of  illustration,  with  a  mass  of  inflamed  hemorrhoids. 

The  color  varies  from  dark  red  to  blood  red  and  '* cyanotic"  rod. 
Soft  infiltration  is  most  often  ioealizod  in  irregular^  disseminated 
centers,  most  commonly  in  the  prostatic  and  membranous  regions. 
These  centers  vary  considerably  in  size,  ranging  from  the  size  of  a 
small  gold  chain  link  to  several  centimeters  in  diameter.  The  number 
of  the  foci  is  also  varial)le;  they  may  be  single  or  more  frequently 


90  '  CYSTOSCOPY   ATTD    URETHROSCOPY 

multiple,  and  in  the  vast  majority  of  instances  are  separated  from  one 
another  by  intervening  healthy  tissue.  Their  shape  is  distinctly  irreg- 
ular ;  the  margins  are  not  well  defined,  but  are  fused  with  thewhealthy 
tissue  surrounding  them. 

The  epithelium  at  first  has  a  brilliant  luster ;  but  when  the  lesions 
have  persisted  for  a  certain  length  of  time,  it  desquamates  or  at  least 
becomes  thinner  and  more  fragile.  It  then  loses  its  luster  gradually 
and  becomes  opaque  and  roughened.  In  places  it  may  disaxjpear  en- 
tirely, and  the  papillar}^  layer  thus  exposed  begins  to  proliferate,  giv- 
ing rise  to  little  granulations  analogous  to  but  less  marked  than  those 
which  are  encountered  in  skin  wounds.  These  petty  granulations  ap- 
pear in  the  guise  of  little  reddish  irregular  specks,  the  surfaces  of 
which  are  red  and  bleed  easily  on  contact.  They  are  very  numerous 
at  the  bulb. 

The  longitudinal  folds  of  the  mucosa  are  materially  changed.  In- 
stead of  the  numerous  folds  which  are  usually  found  on  the  healthy 


W 

Fig.   66. — Kollmann's   pipette,    for   aspirating   the    glandular   secretions. 

mucosa,  only  two  or  three  are  seen,  and  these  are  but  poorly  outlined. 
They  project  into  and  even  obstruct  the  lumen  of  the  canal.  The  longi- 
tudinal striation  is  hardly  visible;  it  is  lost  in  the  hyperemia  and 
tmnefaction  of  the  mass,  the  latter  appearing  only  as  a  uniformly 
smooth  surface. 

The  central  figure  is  almost  always  closed,  so  that  the  aperture 
can  not  be  seen,  even  when  the  tube  is  being  withdrawn.  The  lacunae 
of  the  Morgagni  and  Littre  glands  are  always  involved  in  soft  infil- 
tration. The  inflammatory  process  gives  rise  at  first  to  an  increase  in 
the  glandular  secretion;  their  mucous  covering  is  red  and  slightly 
puffed  up.  Their  excretory  orifices  appear  like  red  projections  as 
large  as  a  pinhead,  forming  a  little  tumefaction  with  raised  and  glassy 
l)orders.  A  mucous  or  purulent  secretion  may  be  seen  escaping  from 
these  orifices;  this  secretion  can  be  collected  for  microscopic  examina- 
tion by  means  of  the  pipette  devised  for  this  purpose  by  Kollmann,  of 
Leipzig  (Fig.  66).  The  lacun?e  of  Morgagni  form  a  projection  at  the 
surface  of  the  mucosa  which  may  attain  the  size  of  a  small  pea;  or  they 
may  appear  like  a  nodule,  the  size  of  a  pinhead,  on  the  top  of  which  a 


IIItK'I'KltOSCOI'Y    OK     NOIt.MAI.    AN'D    I'A'I' 1 1  ( )L( )( ;  IC     I '  IlK'l' 1 1  i;A 


91 


lilllc  ()])('iiiii,i;'  may  somcliincs  lie  seen,  '^riic  (mIj^cs  of  ilic  Inllci'  ai'c 
swollen  and  iraiisluccnl  and  ;i  mucous  or  purulent  sccrcliou  may  bu 
seen  pi'ol  rudiii.i;'  from  llicir  ori  (ice. 

Pa])illomala  may  oricii  accoinpanN'  soft  iiirilti'alioii.  (Vuall>'  small 
and  isolated,  they  may,  nevertheless,  he  Jon<»-,  thin  and  rra<;ile,  or  short 
and  tliick,  ])ro,iectinii,'  into  the  lumen  of  tlie  iiretliroscoi)ic  tul)e.  They 
usual  1>'  resemble  the  type  so  often  seen  on  tlie  prepuce.  They  are  pro- 
duced as  tlie  result  of  the  excessive  proliferation  of  the  mucous  derma 
where  tliey  are  exposed  hj  the  desquamation  of  the  epithelium. 

Occasionally  they  are  gathered  together  in  little  liea])s,  e\-en  to  the 
point  of  ohstructing  the  lumen  of  the  canal.  Their  favorite  site  is  in 
the  hulhous  urethra  or  near  the  verumontanum.  In  one  case,  Ober- 
laender  saw  them  extend  over  the  entire  length  of  the  urethra  and  even 
invade  the  bladder.  Ch-iinfeld  described  these  papillomata  in  his  work 
on  endoscopy."    Several  of  these  are  shown  in  Plate  IT,  Figs.  1  and  2. 

In  the  case  of  a  young  man  aged  twenty-six  years,  referred  to  me 
by  TIartmann,  Avitli  a  chronic  urethritis  of  two  and  a  half  years'  dura- 


Fig.   67. — Little  polypus   situated   at  the   bottom   of   a   lacuna  of   Morgagni. 


tion,  urethroscopy  revealed  a  large  lacuna  of  Morgagni  on  the  anterior 
wall  of  the  penile  urethra  near  the  root,  partially  destroyed.  Two 
floating  shreds  were  attached  to  the  bottom  of  the  lacuna.  On  careful 
examination,  a  little  budding  polypus  Avas  seen  near  the  attachment  of 
the  shreds,  which  constituted  the  debris  of  the  destroyed  lacuna  (Fig. 
67). 

Hard  Infiltration. — As  opposed  to  what  occurs  in  soft  inliltration, 
the  introduction  of  a  urethroscopic  tube  in  a  urethra  affected  with  hard 
infiltration,  presents  a  degree  of  resistance  more  or  less  accentuated  ac- 
cording to  the  amount  and  character  of  the  infiltration.  At  tinu^s  this 
resistance  is  so  marked  as  to  obstruct  the  introduction  of  even  the 
smallest  tu1)e.  In  such  cases  we  are  dealing  with  a  tight  organic 
stricture. 

Lack  of  resilience  is  characteristic  of  all  hard  inliltralions:  this 
being  due  to  the  progressive  transformation  of  tlie  cell  infiltration  in 
the  sui-rouiidiug  tissues.    In  ])roi)ortion  as  lliis  adjaeeiil  tissue  becomes 


PLATE  IV 

Fia.  1. — Glandular  lesions  of  the  anterior  portion  of  the  prostate,  as  seen 
by  the  urethroscope.  The  infected  prostatic  follicles  instead  of  being 
vesicular  and  like  the  spawn  of  a  frog,  as  in  Fig.  1,  show  them- 
selves here  in  the  form  of  real  little  abscesses. 

Fig.  2. — Little  polypus  situated  on  the  apex  of  the  verumontanum. 

Fig.  3. — Pathologic  aspect  of  the  anterior  surface  of  the  chronically  in- 
fiojmed  verumontanum.  "When  a  verumontanum  is  seen  through  the 
urethroscope  so  deformed  and  inflamed,  it  is  reasonably  certain  that 
an  accompanying  inflammation  of  the  seminal  vesicles  exists.  "The 
iirethroscopically  pathologic  ve]-umontanum  is  the  mirror  of  the  seminal 
vesicles. ' ' 


Fig.  1. 


Fi«.  2. 


Fig.  3. 

PLATE  IV 


URETHTIOSCOPY    OF    XOIIArAL    AXD    IWTI  lOLOCIC    URETHRA  93 

more  douse  and  coiiipacl,  llic  l)loo(l  ciiculation  of  tlie  mucosa  is  altered 
and  tlie  tissue  loses  its  normal  color  and  elasticity.  In  extreme  degrees 
of  hyperplasia  oC  llic  adjoiiiiiii;-  tissues,  llic  mucosa  becomes  hard  and 
unj'ielding. 

The  .i^encral  appearance  presented  by  a  mucosa  involved  in  hard 
infiltration  is  characterized  by  a  distinct  diminution  in  color  from 
])ii,<;ht  red  to  ])ale  i^ink  (Plate  Vl,  Fig.  2,  and  Plate  VIT,  Fig.  G).  The 
color  of  the  nmcosa  at  first  pale  and  anemic,  appears  in  the  most  severe 
cases  grayish  or  even  yellowish,  and  later  on,  in  cases  of  true  stricture 
it  becomes  uniformly  grayish  white.  These  various  modifications  in 
color  depend  on  the  more  or  less  active  proliferation  of  cells  in  the  sur- 
rounding tissues.  As  it  increases  in  thickness  and  density,  this  infil- 
tration brings  Avith  it  more  or  less  marked  changes  in  the  blood  circula- 
tion which  l)ecomes  impeded  in  varying  degree.  This  fibrous  tissue 
chokes  the  vessels  and  thus  obstructs  the  blood  stream.  It  is  thus  read- 
ily seen  that  in  cases  of  true  stricture, — those  in  which  the  urethro- 
scopic  examination  can  not  be  made  without  previous  dilatation,  the 
mucosa  appears  uniformly  pale  yellowish  in  color  with  an  appearance 
generally  resembling  gangrene. 

As  in  the  case  of  soft  infiltration,  the  site  of  the  trouble  is  dis- 
tinctly localized;  the  most  common  sites  are  the  midpenile  region,  the 
penoscrotal  junction  particularly,  and  the  membranous  region.  Histo- 
logically the  fibrous  tissue  is  found  principally  near  the  glands;  but  it 
may  also  appear  more  rarely,  in  the  mucous  tissue  itself.  This  tissue 
then  manifests  itself  in  the  form  of  little  cicatrices  about  one  centi- 
meter in  extent  or  in  the  shape  of  little  stars  from  one  to  two  milli- 
meters in  size. 

Degree  oe  Hard  Ixfiltratiox. — The  intensity  of  the  infiltration  be- 
ing variable  in  degree,  the  exact  measure  of  its  extent  is  extremely  dif- 
ficult, if  not  impossible,  to  determine.  Oberlaender  distinguishes  three 
degrees:  1.  That  in  which  the  canal  i^reserves  its  normal  caliber.  2. 
That  in  which  the  canal  though.  narroAved  still  admits  a  Xo.  23  ure- 
throscopic  tube.    3.  That  in  which  a  Xo.  23  tube  can  not  l)e  introduced. 

Thougli  this  classification  is  purely  arbitrary,  nevertheless,  it  is 
one  which  can  be  readily  applied  with  considerable  satisfaction.  A 
more  simple  though  less  exact  classification  can  be  adopted  which  takes 
into  consideration  but  two  types:  mild  types  corresponding  to  the  large 
caliber  stricture  of  Otis,  and  the  more  serious  type,  or  true  stricture. 
In  reality  there  are  so  many  transitional  forms,  which  develop  froni 
the  simple  mild  type  to  the  real  organic  stiicture,  that  it  is  difficult  to 
establish  clean-cut  and  well-defined  classifications. 

The  e])i11i('liuiii   in   hard    innitralion   ])r('sents   ]inth()h)gic   changes 


94  CYSTOSCOPY    AXD    UEETHEOSCOPY 

wliicli  are  due  to  its  defective  nutrition.  In  tlie  first  degree  infiltration, 
the  epitlielium  loses  its  luster  and  transioarency  and  takes  on  a  dull 
appearance.  In  a  more  accentuated  degree  of  infiltration,  a-^process 
of  desquamation  takes  i^lace  due  to  a  proliferation  of  tlie  epitlieliun]. 
these  phenomena  being  found  especially  marked  at  the  point  most  dis- 
eased. The  epithelial  surface  of  the  urethra  then  appears  irregularly 
roughened,  presenting  small  projections  of  about  a  millimeter  in  height 
surrounded  by  rather  large  deiDressions  which  bleed  easily  on  contact. 
The  epithelial  proliferation  results  in  the  formation  of  little  specks, 
fairly  ^vell  marked,  generally  round  and  of  peach  gray  color.  They  are 
of  various  sizes;  sometimes  very  small,  about  the  size  of  a  pinhead,  be- 
ing barely  distinguishable  from  the  surrounding  mucosa:  occasionally 
they  are  thicker  by  several  millimeters,  being  about  a  centimeter  in 
length  and  standing  out  prominently  from  the  adjacent  tissues.  How- 
ever, instead  of  producing  these  small  spots,  the  proliferation  may  ex- 
tend contiguously  to  more  than  half  of  the  urethra.  Li  such  event,  a 
corneous  infiltration  of  the  urethral  epithelium  is  the  result  and  we 
have  to  deal  with  a  thick,  proliferated  surface  Imown  as  pachydermia 
or  leucoj^lakia. 

In  these  cases  the  mucosa  becomes  dull,  grayish  in  color,  with  an 
occasional  spot  showing  the  original  rose  color  of  the  nmcosa.  The  lat- 
ter looks  as  if  it  were  covered  with  a  layer  of  gray  powder. 

Urethral  leucoj^lakia  becomes  localized  usually  in  the  form  of 
plaques  of  varying  extent  with  regular  edges;  they  are  easily  distin- 
guished by  their  lustrous  white,  yellowish  white,  or  grayish  white  color. 
Their  surface  is  not  smooth,  but  granular  and  ''angry."  The  placpies 
are  oval  in  outline  with  their  major  axis  directed  lengthwise  Avith  the 
urethra.  AVhen  they  are  rubbed  with  a  cotton  swab  it  is  seen  that  they 
are  rather  adherent.  The  superficial  layers  may  be  easily  detached  and 
then  the  deeper  mucous  layers  will  appear  dark  red,  dull,  and  wrinkled 
and  do  not  bleed  easily. 

The  longitudinal  folds  of  the  mucosa  diminish  considerably  in 
the  course  of  hard  infiltration,  and  may  even  disappear  entirely  in  the 
serious  cases  which  terminate  in  stricture.  Urethroscopically  the  ure- 
thra assumes  the  appearance  of  a  rigid  j^ipe  which  remains  open  Avhen 
the  uretlirosco23e  is  withdrawn,  due  to  the  fact  that  it  is  a  tissue  with- 
out elasticity  with  stiff  and  smooth  walls.  The  central  figure  is  nearly 
always  transformed  into  a  funnel  witli  deep  and  rigid  walls.  In  true 
stricture  this  funnel  may  measure  one  to  two  centimeters  in  depth. 
The  picture  is  then  absolutely  characteristic.  The  urethral  walls,  re- 
tained by  the  fibrous  tissue  which  surrounds  them,  do  not  come  in  con- 
tact Avitli  one  another  as  in  the  normal  state,  thus  creating  a  funnel,  or 


ui:i-:thi;osc()Py  of  xormal  and  PATiior/Kiic   i'iietiira  v.) 

better  still,  a  tunnel  Avitli  smooth  pale  walls  of  the  ay)])arent  consist- 
ency of  cardhoai'd.  The  lesions  observed  in  hard  infiltration  are  well 
sliown  in  Plate  VI,  Fift".  2. 

Glandular  and  Lacunar  Lesions. — Tlie  lacuna'  of  Moi'.f;a.t>,ni  and  tbe 
glands  of  Littre  arc  always  attacked  in  \-arying'  def:,-ree  in  liai'd  infil- 
tration. Ag-reeing-  witli  Oberlaender,  we  may  distinf;nisli  two  forms, 
(liiitc  dilTci-ciit  from  cadi  other:  (A)  The  excretory  diu-t  remains  pat- 
ent, and  in  this  case  the  contents  of  the  gland  can  i-un  off  and  escape; 
this  is  called  the  "glandular"  tyi)e.  (B)  The  excretory  duct  becomes 
obstructed  by  compression  from  the  neighboring  tissues  or  by  retrac- 
tion of  its  own  walls;  the  secretion  ])roducts  are  then  retained  and  ac- 
cuimdate  in  the  follicle,  thus  transforming  it  into  a  little  cyst.  Tliis 
is  known  as  the  "follicular"  or  "dry"  type.  This  term  "dry"  is  aj^- 
plied  because  of  the  appearance  of  the  mucosa  deprived  of  its  glands; 
but  it  is  accompanied  almost  invarial)ly  by  a  more  or  less  purulent  and 
tenacious  discharge. 

(A)  In  the  "glandular"  form  the  orifices  of  Littre 's  glands  appear 
enlarged  and  surrounded  by  an  inflammatory  ring.  The  orifice  has  the 
appearance  of  a  crater  and  often  gives  forth  a  watery  secretion.  On 
gentle  pressure  of  the  extremity  of  the  urethroscopie  tube  the  lips  of 
the  orifice  will  often  gape  and  a  purulent  and  sometimes  a  clear  liquid 
will  emanate  from  them.  Occasionally  these  orifices  attain  enormous 
size  and  the  pressure  of  the  examining  tube  will  produce  a  veritable 
' '  shower. ' ' 

Morgagni's  lacuna:'  likewise  present  somewhat  similar  changes 
(Plate  VIII,  Fig.  3).  The  edges  of  their  orifices  assume  a  crater-like 
mouth,  from  which  a  mucous  or  purulent  secretion  oozes.  If  on  the 
other  hand  the.  perilacunar  infiltration  is  very  highly  developed,  the 
excretory  ducts  of  the  lacuna?  project  above  the  level  of  the  mucosa 
and  appear  in  the  visual  field  in  the  form  of  little  red  j^rotuberances. 
Where  dilatations  have  already  been  in.-^tituted,  it  is  not  imusual  to 
see  the  glandular  or  lacunar  orifices  which  are  enormously  enlarged, 
split  apart  with  cracked  walls.  This  condition  mav  explain  the  fre- 
quent exacerbations  which  frequently  follow  tlie  fir^t  dilatations. 

Nor  is  the  following  history  unusual  in  these  cases:  A  patient  ])re- 
sents  himself  with  a  very  slight  discharge,  sometimes  nothing  more 
than  the  "morning  drop."  The  urine  being  clear  even  in  the  first  glass, 
and  there  being  neither  pain  nor  any  other  contraindication  against 
the  urethral  examination,  the  physician  introduces  the  bougie  or  some 
other  metallic  instrument  into  the  urethra  in  oi'der  to  determine  the 
presence  of  ]K:)ssil)le  centcfs  of  indui-ation.  Two  days  later  the  ])atient 
returns  in  sui'])risc  with  an  abundant  <lischarge  which  coutains  numer- 


96  CYSTOSCOPY   AND    URETHROSCOPY 

ous  gonococci.  Occasionally  in  the  midst  of  recriminations  addressed 
to  the  physician,  the  latter  is  accused  of  having  produced  the  contam- 
ination by  the  use  of  infected  instruments.  In  reality  the  tru.e  expla- 
nation of  the  occurrence  is  anything  but  that,  and  very  simple  for  any 
one  who  is  familiar  with  urethroscopic  investigation. 

When  observed  through  the  urethroscope,  Littre's  glands  and  Mor- 
gagni's  lacunae  often  appear  in  the  form  of  little  cysts  having  rather 
thin  walls.  These  little  cysts  may  harbor  gonococci  for  a  very  long 
period  of  time,  and  so  long  as  they  are  not  touched,  the  microbes  may 
remain  shut  up  within  their  thin  walls ;  but  it  is  readily  seen  that  when 
an  instrument  is  passed  into  the  canal  and  causes  the  cyst  walls  to 
burst,  the  gonococci  s|)read  themselves  over  the  urethral  mucosa  and 
infect  it  over  again. 

(B)  In  the  ''dry"  or  ''follicular"  form,  as  a  result  of  the  pressure 
exerted  by  the  invasion  of  the  adjoining  infiltration,  the  excretory 
ducts  of  the  glands  are  closed  and  the  glands  themselves  obliterated 
in  such  a  fashion  that  they  are  thus  transformed  into  little  subepithelial 
cystic  cavities  filled  with  a  colloidal  substance.  These  glands  are  at 
times  transformed  into  real  little  purulent  cysts  which  may  be  dissem- 
inated or  grouped  together  into  one  or  more  heaps. 

Some  very  characteristic  views  of  these  lesions  when  the  glands 
have  been  invaded  by  the  infection  may  be  seen  on  Plate  VIII,  Figs.  1 
and  2. 

In  these  ilhistrations,  the  subject  was  a  young-  sergeant  major,  twenty-five  years  of  age, 
stationed  in  Paris.  He  had  a  discha,rge  of  fifteen  months'  duration  for  wliich  irrigations 
and  injections  were  of  no  avail.  Clinically  there  was  nothing  but  a  slight  discharge;  wdiile 
the  clear  urine  contained  but  a  few  filaments  limited  to  the  first  glass.  The  urethra  accepted 
a  No.  21  b'ougie  easily.  Inspection  of  the  penile  urethra  through  the  urethroscope  resulted  in 
the  discovery  of  a  series  of  numerous  little  white  spots  which  gave  the  mucosa  a  granular 
appearance  resembling  a  flower  bed  of  purulent  whitish  points.  Individually  each  one  of 
these  points  was  very  small,  but  there  were  many  of  them;  each  one  represented  an  inflamed 
Littre's  gland  filled  with  purulent  contents. 

Considering  the  infinite  number  of  affected  glands,  it  was  impossible  to  dream  even  of 
attacking  them  singly.  It  was  decidedly  more  rational  to  treat  them  locally  but  en  tloc. 
This  was  accomplished  by  gross  dilatation  with  the  Kollmann  straight  dilator.  In  two  months 
there  was  a  great  improvement,  but  he  was  not  yet  cured.  Another  urethroscopic  examination 
was  then  made,  and  revealed  an  exceedingly  interesting  state  of  affairs :  At  the  penile  urethra 
the  mucosa  had  recovered  its  normal  appearance,  and  the  many  little  purulent  cysts  had  dis- 
appeared owing  in  all  probability,  to  the  fact  that  the  maximum  amount  of  dilatation  had 
been  accorded  this  portion  of  the  urethra  by  the  complete  separation  of  the  arms  of  the 
Kollmann  dilator.  On  the  other  hand,  in  the  remaining  portion  of  the  urethra  nearer  the 
meatus  which  had  not  received  so  thorough  a  dilatation,  tlie  little  pus-bearing  cysts  were  still 
visible  as  before. 

The  disappearance  of  a  large  numl)er  of  these  purulent  cysts  through  dilatation  had 
brought  about  a  notable  improvement,  but  the  cure  could  not  be  complete  since  the  former 
condition  had  not  been  entirely  removed.     However,  dilatation  at  the  only  points  which  still 


URETHROSCOPY    OF-'    NORMAL    AND    PATWOIAHWC    URETHRA  97 

roniiiiiicil  inl'cctcd  i-i'sull<'i|    in   icsf (iiiii;;  tli<'  niucnsii  [o  its  iioiniiil   ;iii[ii';naiic('  iind   wilii   it  gave 
till'  patiiMit  a  perfect  cure. 

These  cysts  (Plate  VII,  V'v^.  '.])  may  Ix'  iiiiu-li  lnr,i;('i-  in  si/c  so  llial 
tliey  may  pi'oject  into  tlie  luiiieii  of  tlio  iircitliral  canal.  They  may  burst 
under  the  eye  of  tlie  observer  hy  the  mere  jjressure  of  the  uretliroscope, 
inundating  the  uretliroscopic  fiehl  with  their  contents. 

The  following  is  a  case  Mliich  is  not  at  all  rare,  as  T  have  observed 
it  several  times,  i)articnlarly  in  the  case  of  a  patient  of  Dr.  Chenrlot. 
This  man,  twenty-six  ^^ears  of  age,  with  an  attack  of  urethritis  of 
one  and  a  half  years'  duration,  had  a  numher  of  these  cysts  throughout 
the  entire  penile  urethra.  Methodical  dilatation  succeeded  in  causing 
the  comjDlete  disappearance  of  the  lesions  and  the  patient  was  entirely 
cured. 

I  have  encountered  a  still  more  typical  case  in  which  Littre's 
glands  were  changed  into  cysts  similar  to  that  illustrated  in  Plate  VIT, 
Fig.  3.    The  historj^  of  the  case  is  as  follows: 

The  patient  was  a  young  man  of  twenty-iive,  who  had  had  a  discharge  for  eleven 
moitths.  Examined  microscopically  it  was  found  to  contain  only  leucocytes  and  cells.  The 
urine  was  clear,  but  contained  large  heavy  shreds  limited  to  the  first  glass.  The  urethra, 
though  presenting  spasmodic  resistance,  was,  nevertheless,  absolutely  free  to  No.  20.  A  series 
of  silver  nitrate  instillations  produced  almost  no  result.  Urethroseopic  examination  of  the 
anterior  urethra  showed,  in  the  midpeiiile  portion,  a  considerable  number  of  enlarged  Littre's 
glands  making  a  slight  projection  into  the  lumen  of  the  .urethroscoi^e  and  apparently  covered 
over  by  a  fine  whitish  cuticle.  One  of  these  glands  was  quite  large  and  distinctly  ajDpeared  to 
be  a  typical  cyst.     This  is  shown  in  the  picture  above  referred  to. 

Methodical  dilatation  of  the  anterior  urethra  with  the  Kollmann  dilator  was  made 
over  a  period  of  three  months.  At  tlie  end  of  that  time  No.  44  had  been  reached  without 
untoward  incident  and  the  patient  had  no  longer  any  trace  of  discharge.  The  urine  was 
clear  and  without  shreds.  Finally,  a  urethroseopic  examination  demonstrated  the  complete  dis- 
appearance of  all  the  cysts  in  the  penile  urethra  and  an  absolutely  normal  mucosa  in  that 
portion  of  the  canal. 

Numerous  cases  are  encountered  of  the  dry  or  follicular  variety  in 
which  the  excretory  ducts  of  Littre's  glands  are  obliterated,  but  in 
which,  nevertheless,  the  glands  still  project  through  the  nnicosa  and 
are  consequently  still  visible  through  the  urethroscope.  Quite  numer- 
ous also  are  the  instances  in  which  the  proliferation  of  the  urethral 
epithelium  and  of  the  surrounding  infiltration  at  the  mucous  surface  is 
so  great  that  the  glands  are  forced  back  into  the  deej^er  structures. 
These  are  the  cases,  and  they  are  by  far  the  worst,  which  offer  the 
greatest  resistance  to  treatment,  and  are  the  most  difficult  to  cure. 

Palpation  of  the  urethral  mucosa  stretched  over  a  Benique  sound 
gives  very  exact  and  important  information  in  these  cases.  Indeed 
when  the  sound  lias  Ixhmi  insci-lcMl  into  llic  iircUii'a,  if  the  lower  wall 
of  the  urethra  is  ])alpated,  many  very  clear  small  pi'ojections  will  ol'ten 


98  CYSTOSCOPY   AND   URETHROSCOPY 

l)e  discovered.  These  are  usually  separated  from  one  another,  rounded 
like  little  cysts,  and  vary  in  size  from  that  of  a  millet  seed  to  a  hemp- 
seed.  At  times  they  may  attain  a  size  approximating  a  hazislnut,  or 
even  a  walnut.  They  may  rupture  externally  and  ultimately  result  in 
a  urinary  fistula. 

Having  observed  the  exact  location  of  one  of  these  little  projec- 
tions in  the  urethra  with  the  sound,  the  urethroscope  is  introduced  and 
the  appearance  of  the  mucosa  at  that  particular  point  carefully  studied. 
By  inclining  the  tuhe  laterally  so  as  to  put  the  mucosa  on  the  stretch, 
nothing  more  than  a  smooth  mucosa  with  few  if  any  glandular  orifices 
visible  Avill  sometimes  be  seen.  This  fact  proves  that  the  gland  has 
been  comi)letely  obliterated  and  that  it  does  not  any  longer  communi- 
cate with  the  mucosa. 

The  following  case  is  absolutely  typical  of  these  conditions: 

A  young  externe  of  the  Paris  liospitals,  twenty-four  years  old,  contracted  a  gonorrhea 
and  had  been  treating  it  for  three  months.  At  the  end  of  that  time,  there  was  no  discharge 
except  a  slight  morning  drop.  When  he  came  to  me  on  October  5,  1903,  he  complained  of 
having  noticed  for  three  weeks  past,  a  little  tumor  situated  on  the  lower  surface  of  the 
urethra  about  five  centimeters  from  the  urinary  meatus.  This  little  tumor,  at  first  the  size 
of  a  pea  and  of  a  consistency  of  a  lead  shot,  had  suddenly  increased  in  size  during  the  pre- 
ceding six  days  and  had  attained  the  size  of  an  olive.  The  pressure  produced  by  this  swell- 
ing had  caused  edema  of  the  foreskin;  rupture  of  the  mass  with  a  subsequent  urethral  fistula 
seemed  inevitable. 

In  the  presence  of  these  well-defined  sjmiptoms  I  decided  to  make  an  examination  with 
the  urethroscope.  Tlie  tube  having  been  introduced  rather  deeply  and  withdrawn  gradually 
I  was  enabled  to  recognize  a  distinct  point  which  indicated  that  I  had  reached  the  tumor.  I 
noticed  this  curious  fact, — that  w^hile  the  swelling  was  as  large  as  an  olive  and  bulged  clearly 
and  distinctly  externally,  it  projected  very  slightly  if  at  all,  into  the  urethroseopic  tube.  Bring- 
ing the  tube  to  the  level  of  the  tumor,  I  cut  the  mucosa  deliberately  with  a  small  Kollmann 
knife  and  plunged  the  blade  into  the  swelling.  In  spite  of  a  rather  large  incision,  nothing  but 
blood  appeared.  I  then  fixed  the  tube  and  the  penis  with  one  hand,  and  made  pressure  firmly 
on  the  tumor  with  the  other  hand,  and  squeezed  it  quite  vigorously.  All  at  once  I  saw  a 
slough  of  flimsy  stuff  shoot  forth  which  closely  resembled  the  slough  squeezed  out  of  a 
furuncle.  Tlie  tumor  diminished  in  size  slightly  for  the  moment  but  it  was  still  quite  large 
and  presented  a  fibrous  shell  of  great  resistance  and  toughness. 

The  after-effects  of  the  operation  were  quite  uneventful.  The  edema  disappeared  some 
days  afterwards,  and  the  patient  was  soon  able  to  commence  methodical  dilatation  of  his 
anterior  urethra  with  straight  sounds.  This  dilatation  was  pushed  up  to  No.  60  Benique.  I 
saw  the  patient  five  months  later,  i.  e.,  in  March,  1904.  He  then  no  longer  had  any  discharge 
and  in  place  of  the  tumor  nothing  could  be  felt  except  a  little  fibrous  core  about  the  size  of 
a  hempseed. 

This  case  is  interesting  in  more  than  one  respect:  It  teaches  the 
following:  1.  That  when  the  glands  have  lost  their  communication  with 
the  surface  of  the  urethral  mucosa,  urethroscopy  gives  no  information 
as  to  their  location  and  condition.  2.  That  the  contents  of  these  fol- 
licles is  not  fluid,  but,  on  the  contrary,  is  made  up  of  a  slough  similar  to 
that  of  a  furuncle.     3.  That  the  fibrous  infiltration  surrounding  the 


URETHROSCOPY    OF    NORMAL   AND    PATHOLOGIC    URETHRA  99 

glandular  walls  constitutes  tlie  essential  cliaracteristic  of  these  cysts. 
4.  That  it  is  easy,  with  the  aid  of  the  urethroscoije,  to  attack  these 
glands  surgically  when  they  threaten  to  suppurate.  In  this  way,  spon- 
taneous rupture  externally  might  be  avoided  and  thus  prevent  the  de- 
velopment of  a  consequent  urinary  fistula. 

The  excretory  ducts  of  the  lacunae  of  Morgagni  also  may  become 
obliterated  and  eventually  become  choked  up  with  their  contents.  The 
urethroscopic  appearance  is  absolutely  typical.  The  glandular  orifices 
are  barely  seen,  if  at  all.  Here  and  there  instead  of  a  lacunar  orifice 
a  small  grayish  or  yellowish  depression  is  noticed  indicative  of  a  closed 
follicle  and  which  resembles  a  little  button  about  the  size  of  a  millet 
seed.  These  are  the  follicles  which  can  be  felt  on  external  palpation 
of  the  urethra. 

I  have  had  a  case  of  this  kind  (Plate  VII,  Fig.  4)  in  which 
there  was  an  apparent  obliteration  of  a  lacuna  of  Morgagni.  It  oc- 
curred in  the  case  of  a  man,  twenty-nine  years  of  age,  who  had  had  a 
chronic  urethritis  for  a  year,  characterized  by  a  urethral  discharge  and 
multiple  points  of  infection;  i.  e.,  chronic  prostatitis,  hard  infiltrations 
in  the  perineal  region,  and  glandular  and  lacunar  lesions  in  the  penile 
urethra.  On  the  upper  wall  of  the  urethra,  urethroscopy  revealed  a 
small,  smooth  oval  projection  about  as  large  as  a  grain  of  corn  cov- 
ered over  with  a  yellow  mucosa  and  presenting  only  some  reddish 
striations. 

Dilatation  of  this  lesion,  even  with  the  straight  Kollmann  dilator 
up  to  No.  42,  produced  no  ai^preciable  effect  and  its  appearance  after 
treatment  was  practically  the  same  as  before  it  was  begun.  Tavo  or 
three  applications  of  Kollmann 's  electrolytic  needle  quite  close  together 
sufficed  to  bring  about  a  cure  at  one  sitting;  after  this  application,  not 
a  single  trace  of  the  lesions  could  be  observed. 

It  is  not  rare  to  find  the  glandular  and  dry  varieties  of  hard  infil- 
tration in  the  urethra  at  the  same  time.  This  constitutes  the  ''mixed" 
type.  Exceptionally  this  mixed  form  is  found  at  the  very  beginning 
before  any  treatment  has  been  instituted.  Most  frequently  it  is  ob- 
served when  the  dry  variety  is  treated  by  dilatation;  in  such  cases  the 
cysts  open  and  become  atrophied  or  destroyed;  the  excretory  glandular 
ducts  that  have  become  free  open  externally  and  gradually  we  thus 
pass  to  the  "mixed"  and  subsequently  to  the  glandular  type. 

REFERENCES 

lObcrlacnder  and  Kollmann:      Die  clnonisclie  Gononhoe  (lev  mannlichen  Hai'niolirc,  Leipzig, 

Georg  Thicm,  ed.  2,  revised,  1910. 
-De  Keersmacckcr   and  Verhoogen :      L'ututritc   clnonique   d'origine   gonococcique,   Bruxelles, 

Lamertin,  1898. 


100  CYSTOSCOPY   AND    URETHROSCOPY 

^Wossidlo:     Die  Gonorrhoe  ties  Mamies,  Leipzig,  Georg  Thiem,  ed.  2,  1909. 

4Janet :     Ann.  d.  mal.  d.  org.  genito-urin.,  1891 ;  Endoseopie  uretrale,  iu  Lecons  cliniques  de 

Guyon,  Paris,  1903. 
EFraisse:     Gonorrhee  chrouique  de  I'homme,  Paris,  Maloine,  1910. 
sGriinfeld:     Die  Endoseopie  der  Harnrohre  und  Blase,  Deutsch.  Chir.,  von  Billroth  und  Luecke, 

Lieferung  51,  1881. 

5.  Urethroscopy  of  the  Pathologic  Posterior  Urethra 

In  all  cases  of  chronic  urethritis  it  is  absolntely  necessary  to  ex- 
amine the  entire  posterior  urethra  and  not  to  limit  the  examination 
to  the  anterior  surface  of  the  verumontanum ;  the  entire  prostatic  fos- 
sette  [postmontane  space]  beginning  with  the  neck  of  the  bladder  must 
likewise  be  examined  and  studied  thoroughly. 

Clinically  this  particular  portion  of  the  canal  does  not  present  any 
special  symptoms;  nevertheless,  it  is  often  surprising  to  see  lesions  of 
the  posterior  urethra  that  pass  entirely  unnoticed  even  by  competent 
physicians  and  which  can  not  be  discovered  by  any  other  means  than 
the  urethroscope.  Very  often  when  the  patient  does  not  complain  of 
any  special  sensation  on  the  part  of  the  prostate  and  when  his  second 
glass  of  urine  is  clear  without  shreds  or  filaments;  when  the  rectal  ex- 
amination does  not  disclose  any  marked  inflammation  of  the  prostate 
and  when  even  the  most  energetic  massage  of  the  prostate  brings  forth 
but  very  little  prostatic  secretion  and  this,  almost  normal, — even  in 
these  circumstances,  where  everything  combines  to  force  the  conclusion 
that  the  posterior  urethra  is  normal,  such  may  not  be  the  case.  In 
point  of  fact,  a  urethroscopic  examination  of  the  posterior  urethra 
often  reveals  the  fact  that  well-marked  lesions  exist  in  the  posterior 
urethra  which,  properly  treated,  will  bring  about  a  complete  cure  in 
cases  hitherto  believed  to  be  almost  incurable.  In  these  instances,  if 
chronic  prostatitis  is  not  responsible  for  the  lesions,  then  surely  chronic 
posterior  urethritis  must  be  the  etiologic  factor. 

In  an  interesting  article,  Wolbarst,  of  New  York,^  has  also  justly 
insisted  on  the  necessity  of  examining  the  verumontanum  with  the  ure- 
throscope in  all  cases  of  chronic  urethritis.  In  his  opinion,  it  is  essen- 
tial in  all  cases  of  spermatocystitis  to  treat,  not  only  the  seminal  ves- 
icles, but  also  to  treat  thoroughly  the  verumontanum  and  the  ejacula- 
tory  ducts  by  means  of  the  urethroscope.  This  author  has  published 
reports  in  which  he  demonstrated  the  fact  that  treatment  of  the  sem- 
inal vesicles  alone  is  not  sufficient  to  bring  about  a  complete  cure  and 
that  it  is  absolutely  necessary  to  examine  and  treat  the  verumontanum 
locally  as  well. 

The  local  urethroscopic  treatment  which  he  recommends  is  the  di- 
rect application  of  a  10  per  cent  solution  of  silver  nitrate  or  dilute 


URETHROSCOPY   OF    NORMA!.   AND    PATItOI/JGlC    URETHRA  101 

tincture  of  iodiii;  also  applications  ol'  llic  galvaiiocautci-y  and  Oudiii's 
jiigli  frequency  current   (sparking). 

Soft  infiltration  is  the  most  frequent  lesion  encountered  in  pos- 
terior urethritis.  The  mucosa  is  hyperemic,  congested,  and  bleeds 
easily  on  tlie  slightest  contact.  The  verumontanuni  involved  in  soft 
infiltration  is  dark  red  in  color,  swollen,  and  increased  in  size.  It  takes 
on  a  smooth  ajopearance  and  becomes  distorted  in  shape.  The  orifice 
of  the  prostatic  utricle  is  open-mouthed,  inflamed,  and  gives  forth  a 
nmcous  or  purulent  secretion.  Very  often  the  swelling  of  the  verumoii- 
tannm  is  so  pronounced  that  this  orifice  as  well  as  those  of  the  ejacula- 
tory  ducts,  is  lost  in  the  thickened  mucosa,  and  remains  hidden  from 
view.    When  these  orifices  and  those  of  the  prostatic  follicles  can  be 


Fig.   68. — Urethroscopic    lesions    of    the    prostatic    fossette,    behind    the    verumontanuni. 

seen,  they  appear  red,  swollen,  and  surmounted  with  overhanging 
margins. 

Laterally,  the  ejaculatory  orifices  may  be  seen  occasionally,  more 
or  less  filled  with  pus.  Thus  in  a  case  of  left  chronic  epididymo- 
orchitis  of  gonococcal  origin,  I  saw  pus  emanating  from  the  left  ejacu- 
latory duct;  above,  was  the  verumontanum,  very  much  congested  and 
displaced  considerably.  The  membranous  region,  congested  and  even 
cyanosed  comiDletely  loses  its  luster;  its  folds  become  larger  and  more 
swollen  and  the  nmcosa  projects  into  tlie  urethroscopic  tube  like  a  her- 
nia. It  is  quite  customary  to  find  the  mucosa  of  the  posterior  urethra 
markedly  swollen  and  manifesting  itself  in  the  form  of  bullous  edema, 
concentrated  more  or  less,  and  bleeding  readily  (Fig.  68). 

The  prostatic  follicles  are  very  often  the  seat  of  chronic  inflam- 
mation; their  orifices  often  appear  red,  swollen,  and  sui'rounded  with  a 
projecting  and  overhanging  margin.    Coldschmidt  has  justly  compared 


102  CYSTOSCOPY   AXD    UEETHEOSCOPY 

them  to  frog's  eyes.  At  other  times  the}^  appear  like  little  iDurnlent 
masses  adjoining  one  another  taking  the  form  of  little  white  buttons, 
often  acuminated  and  simulating  boils.  It  is  well  to  note  that  this 
chronic  inflammation  of  the  iDrostatic  follicles  not  only  lies  behind  the 
verumontanum  on  the  inferior  urethral  wall,  but  also  on  the  anterior 
superior  wall  of  the  urethra,  as  is  well  shown  in  Figs.  68  and  69;  it 
may  likewise  be  observed  in  the  lateral  gutters  or  grooves  situated  on 
either  side  of  the  base  of  the  verumontanum. 

For  this  reason  the  examination  of  the  posterior  urethra  with  the 
simple  straight  tube  seems  to  give  results  infinitely  preferable  to  those 
obtained  with  instruments  designed  specially  for  the  posterior  urethra. 
With  Goldschmidt 's  instrument,  for  examiDle,  the  anterosuj)erior  wall 


Fig.   69. — Glandular    lesions    of    the    anterior   surface    of    the   ijrostate,    seen    with    the    urethroscope. 

of  the  prostatic  urethra  can  not  be  examined  Avithout  great  difficulty; 
in  using  this  instrument,  therefore,  distinct  lesions  of  the  posterior 
urethra  might  be  entirely  overlooked. 

The  following  rejDort  of  a  case  of  chronic  jDosterior  urethritis,  with 
gonococci  in  the  prostatic  focus,  is  of  particular  interest  in  this  con- 
nection : 

A  man,  forty-four  years  of  age,  referred  to  me  by  Portalier,  had  an  attack  of  gonorrhea 
ten  years  previously  wliich  was  treated  simply  with  irrigations  of  permanganate.  For  ten 
years  he  had  not  noticed  any  apx^reciable  discharge.  Suddenly  on  May  6,  1910,  the  patient 
developed  a  profuse  discharge  containing  typical  gonococci.  Greatly  astonished  by  the  ap- 
pearance of  the  discharge,  he  at  once  suspected  his  mistress  and  requested  me  to  examine  her. 
On  two  different  occasions  the  most  careful  examination  of  the  young  woman  was  made,  and 
notwithstanding  the  greatest  care,  I  could  not  discover  any  possible  infected  focus  which  might 


URETHROSCOPY   OF    NORMAL   AND   PATHOLOGIC    URETHRA  103 

harbor  gonococci.  The  examinations  included  a  uretliroscopic  examination  of  the  urethra, 
examination  of  the  paraurethral  glands,  Bartholin's  glands,  the  posterior  vaginal  cul-de-sac, 
and  the  cervical  neck,  which  was  scraped  with  a  platinum  loop.  The  rectum  was  also  exam- 
ined and  found  entirely  normal.  In  a  word,  the  young  woman  seemed  absolutely  healthy  and 
free  from  all  gonococcal  infection. 

The  problem  was  to  discover  the  origin  of  this  mysterious  infection.  After  some  days 
of  irrigation  with  permanganate,  the  discharge  disappeared  gradually  and  dried  up  completely. 
The  urine,  at  first  turbid,  slowly  cleared  up  to  such  an  extent  that  a  uretliroscopic  examina- 
tion could  safely  be  undertaken  on  May  27,  twenty-one  days  later.  To  my  great  surprise, 
I  found  that  the  canal  was  perfectly  normal  behind  the  verumontanum  up  to  the  vesical 
neck;  but  at  the  verumontanum  and  in  front  of  it  there  were  well-marked  lesions  of  soft 
infiltration.  At  this  point,  examination  showed  bullous  edema,  little  polypi  and  polypoid 
forms  in  great  abundance,  together  with  an  edematous  thickening  of  the  mucosa.  The  bulb 
and  the  penile  urethra  were  apparently  perfectly  normal.  It  appeared  then  as  if  this  was 
a  manifestation  of  a  very  old  chronic  posterior  urethritis  which  had  permitted  the  gonococci 
to  remain  latent  for  a  period  of  ten  years  and  which  suddenly  reappeared  at  the  end  of  that 
period. 

Gross  dilatation  of  the  urethra,  at  first  with  Benique  sounds  then  with  Franck's  three 
armed  dilator  soon  resulted  in  a  complete  cure  of  the  patient.  Urethroscojoic  control  was  in- 
stituted after  the  application  of  Franck's  dilator,  and  gave  positive  proof  of  the  complete 
disappearance  of  all  the  lesions. 

Another  instance  of  the  same  kind  is  also  quite  characteristic: 

A  man  of  forty-five  showed  a  discharge  containing  gonococci  for  six  months.  He  had 
been  treated  by  Wormser  with  urethrovesical  irrigations  of  permanganate  followed  by  gradual 
and  methodical  dilatation  of  the  urethra  with  curved  sounds  up  to  No.  56.  At  the  same  time 
he  had  had  an  acute  inflammation  of  Tyson's  gland  which  was  incised  externally  and  com- 
pletely disinfected.  In  spite  of  this  scientific  and  methodical  treatment,  the  patient  showed 
a  recurrence  of  the  discharge  with  gonococci  as  soon  as  the  irrigations  were  suspended  for  a 
short  time.  It  was  therefore  believed  that  there  existed  somewhere  a  permanent  gonococcal 
focus. 

To  discover  the  location  of  this  focus,  Wormser  sent  the  patient  to  me  on  June  6,  1910. 
Examination  of  the  urethra  stretched  over  a  straight  Benique  sound  gave  evidence  o.f  the 
presence  of  enlarged  Littre  glands;  the  prostate  presented  only  minor  changes;  CoA\'per's 
glands  and  the  seminal  vesicles  were  ajDparently  normal;  the  epididymes  showed  no  evidence 
of  a  previous  inflammation. 

Urethroscopy  showed  a  normal  anterior  urethra,  but  the  posterior  canal  revealed  a  num- 
ber of  well-defined  lesions.  These  consisted  of  little  white  vesicles  very  well  marked,  which 
lay  just  above  the  verumontanum.  "When  they  were  touched  with  a  cotton  swab  they  did 
not  become  detached  and  the  swab  slipped  over  them  without  their  being  ruptured.  In  view 
of  these  findings,  I  recommended  that  Wormser  continue  the  treatment  which  he  had  so 
well  begun  and  maintained,  and  continue  the  dilatation  still  further.  The  patient  was  then 
dilated  up  to  No.  60  Benique. 

Four  days  later,  however,  the  irrigations  having  been  temporarily  suspended,  the  dis- 
charge reappeared  and  was  again  found  to  contain  gonococci.  I  examined  him  again 
urethroscopically  on  July  1,  1910,  and  was  able  to  note  that  the  lesions  which  I  had  observed 
near  the  verumontanum  were  still  present  and  had  not  been  changed  at  all.  This  latest  re- 
currence was  then  easy  to  account  for.  In  agreement  with  Wormser  I  began  dilatation  with 
Franck's  dilator,  pushing  it  to  its  extreme  limit,  this  being  attained  on  July  13,  1910. 

Following  this  treatment,  the  patient  having  gone  six  days  without  a  permanganate 
irrigation,  or  any  other  treatment,  he  wrote  me  that  his  condition  at  the  time  was  quite 
satisfactory,  that  there  was  no  relapse  of  the  discharge  and  tliat  his  urine  was  clear.  The 
dilatation  had  seemed  to  produce  the  desired  effect,  and  the  focus  which  had  harbored  the 


PLATE  V 

Fig.  1. — Curious  patJwlogic  aspect  of  the  verumontanum.  The  prostatic 
utricle  instead  of  being  placed  on  the  anterior  surface  of  the  verumon- 
tanum is  detached  and  thus  forms  a  distinct  pocket.  This  case,  ob- 
served in  a  man  thirty-one  years  of  age,  referred  to  me  by  Gaston 
Alexandre,  is  especially  interesting  by  reason  of  the  sterility  which 
was  the  inevitable  consequence  of  this  pathologic  condition.  This  pa- 
tient, who  was  anxious  to  have  children,  found  it  impossible  to  pro- 
create; for  at  the  moment  of  ejaculation  the  semen  accumulated  in 
the  j)Ocket  of  the  prostatic  utricle  and  could  not  be  projected  forward, 
the  seminal  fluid  oozing  out  some  minutes  later  through  the  urethra. 

Fig.  2. — FathoJogic  aspect  of  a  chronic  inflammation  of  the  verumontanum  in 
a  case  of  chronic  spermatocystitis. 

Fig.  3. — Unusual  appearance  of  the  ejaculatory  ducts.  This  was  a  case 
in  which  chronic  relapses  of  gonococcal  urethritis  were  suppressed  only 
by  cauterization  of  the  verumontanum.  This  had  to  be  destroyed  by 
the  actual  cautery,  thus  leaving  the  ejaculatory  ducts  exposed  like  two 
gun  barrels  lashed  together. 


FiR.    1. 


Fig.  2. 


PLATE  V 


Fig.  3. 


URETHROSCOPY    OF    XORAEAL    AXD    rATlfOLOGIC    UUETIIRA  105 

ooniiciicci  i'(jr  sui-Ii  u  \ini'^  pcriml  liail  ;i|ijiarciitly  l)C(>ii  destroyed  conijiletoly.  As  a  coiifirma- 
tidii  of  tliis  jit'ilcct  cure  of  the  patient,  I  siiw  iiiiii  ii{;aiii  on  July  25,  IfllO.  Havin<r  gone  for 
a  fortnight  without  any  treatment,  he  clechired  witli  great  pleasure  that  there  was  no  dis- 
charge and  Ills  urine  was  clear  without  the  slightest  trace  of  filaments  or  ^reds. 

"With  tlic  urclliroppopo  I  notifod  that  there  no  longer  existed  any  evidence  of  a  purulent 
cyst  or  a  |iath(il(ii;ic  focus  iu  tlic  ]inst('rior  urctlira  liiat  might  act  as  a  nidus  for  the  gonococcus. 
The  veruinonttinum  still  showed  the  presence  of  a  sliglit  chronic  inflammati-on,  this  being 
made  evident  by  a  distinct  edematous  appearance.  I  cauterized  the  summit  and  painted  the 
entire  body  of  the  verumontanum.  lightly  witii  tincture  of  iodin.  From  that  time  on,  the 
cure  was  complete  and  the  gonococei  never  returned. 

Dc'svif^iies,  of  Limoges,  lias  imblislied'  the  following  interesting  re- 
port on  this  subject : 

''On  Dec.  28,  1910,  B.,  aged  thirty-four  years,  presented  himself  for  consultation  to  our 
chief,  Luys,  complaining  of  a  morning  drop.  He  had  contracted  gonorrhea  a  year  previously 
and  had  been  treated  with  irrigations  of  permanganate  and  oxycyanide  of  mercury.  A  series 
of  local  applications  of  silver  nitrate  had  been  made  and  large  Beniquc  sounds  up  to  No.  60 
had  been  passed. 

' '  The  urine  presented  large  heavy  shreds  in  the  first  glass  and  the  fourth  glass  was 
clear.  Microscopic  examination  of  the  morning  drop  revealed  the  presence  of  numerous  leuco- 
cytes with  a  few  diplococci  wliicli  did  not  resemble  the  gonococcus.  The  meatus  was  normal ; 
the  foreskin  free,  no  paraurethral  fistula.  Per  rectum,  the  prostate  and  seminal  vesicles  were 
negative ;  likewise  the  massaged  ex2:iression  of  these  glands ;  Cowper  's  glands  also  negative. 

.''Luys  then  decided  to  ajiply  urethroscopy,  using  his  instrument  with  tube  Xo.  60.  In 
tlie  posterior  urethra,  he  noted  the  following:  At  the  upper  part  of  the  prostatic  fossette, 
three  large  edematous  and  whitish  projections  indicative  VDf  a  chronic  prostatitis,  constituting 
a  hernia  into  the  urethroscopic  tube.  The  entire  mucosa  of  the  posterior  urethra  was  uni- 
formly red.  In  the  anterior  urethra  he  noted  a  slight  hardening  of  the  bulbous  region;  a  few 
Littre"s  glands  were  situated  on  the  .upper  wall. 

' '  The  anterior  urethra  was  dilated  with  a  straight  Kollmann  dilator  up  to  Xo.  90 ;  then 
dilatation  of  the  posterior  urethra  with  a  curved  Kollmann  was  alternated  with  massage  of 
the  prostate. 

"April  6:  The  patient  had  no  morning  drop  but  still  showed  some  filaments  in  the 
first  glass  of  urine.  Urethroscoj)y :  The  minor  lesions  'of  the  anterior  urethra  had  dis- 
appeared, and  the  appearance  of  the  posterior  urethra  had  changed  considerably.  It  was 
much  less  inflamed  and  in  place  of  the  large  edematous  circumscribed  projections  in  the 
prostatic  fossette  three  whitish  vesicles  which  seemed  purulent  in  character,  were  observed. 
These  vesicles  were  cauterized. 

' '  Ten  days  later  cauterization  was  repeated.  The  ijaticnt  reported  feeling  much  bet- 
ter and  presented  nothing  but  a  few  thin  floating  filaments  in  the  first  urine.  All  treatment 
was  now  suspended.  The  patient  was  seen  again  early  iu  June,  1911,  and  had  no  filaments 
whatever  in  the  urine. 

"In  conclusion,  this  rej^ort  indicates  clearly  that  through  urethroscopy  alone  was  a 
correct  diagnosis  and  appropriate  treatment  made  jjossible  in  this  case,  which  had  resisted 
all  other  tlierapeutic  nu'thods  at  our  command." 

The  study  of  the  prostatic  fossette  is  extremely  interesting  in 
chronic  prostatitis.  It  is  Avell  to  rememher,  in  this  connection,  that  the 
orifices  of  the  infected  follicles  open  on  the  lloor  of  the  fossette.  Look- 
ing at  this  region  through  the  urethroscope  Avhih^  the  i3rostatic  lobes 
are  massaged  with  one  finger  in  the  rectum,  streams  of  pus  may  be 
seen  gushing  forth  from  the  infected  glands.     The  glandular  oritices 


106  CYSTOSCOPY   AXD    rEETHROSCOPY 

from  ^vliicli  jdus  is  most  frequently  evacuated  are  found  on  the  lateral 
margins  of  the  Termnontanum  on  a  level  with  its  base. 

In  two  cases  of  chronic  prostatitis  which  were  apiiarentl^^  abso- 
lutely incurable,  I  have  been  able  to  observe  that  pus  exuded  from  sev- 
eral gland  orifices  on  the  side  of  the  verumontanum  Avhen  pressure  was 
exerted  on  the  prostate  through  the  rectum.  In  these  two  cases,  I 
succeeded  in  greatly  enlarging  these  orifices,  which  had  caused  reten- 
tion of  the  iDus  because  they  were  too  narrow. 

In  a  man  thirty-four  years  of  age,  the  orifice  was  enlarged  with  a 
galvanocautery  point  and  behind  it  we  found  a  real  "prostatic  cavern" 
(Plate  A%  Fig.  1).  This  was  subsequently  easily  disinfected  with 
swabs  of  cotton  steeped  in  silver  nitrate  or  resorcin.  In  both  cases  I 
was  specially  struck  with  the  enormous  dimensions  of  these  prostatic 
caverns.  "With  the  original  orifice  so  narrow,  the  great  size  of  these 
caverns  is  not  usually  susiDected.  It  is,  therefore,  evident  that  these 
urethroscopic  researches  are  of  the  greatest  importance,  for  it  is  only 
by  their  aid  that  we  are  able  to  find  the  solution  of  the  problem  so  often 
placed  before  us;  namely,  the  cure  of  these  old  and  seemingly  incural)le 
cases  of  prostatitis. 

Localization  of  chronic  urethritis  in  the  posterior  urethra  is  ex- 
tremely common,  notwithstanding  the  general  belief  to  the  contrary. 
It  is  true  that  in  an  acute  inflammation,  it  is  im^DOSsible  to  make  ure- 
throscopic observations  because  of  the  hyperemic  condition  of  the 
mucosa;  in  the  chronic  stage,  however,  when  the  entire  posterior  ure- 
thra can  be  examined  deliberately  and  carefully,  the  reason  for  the  ex- 
istence of  otherwise  inexplicable  s^^miptoms  will  usually  be  revealed. 

The  posterior  urethra  is  seriously  altered  in  hard  infiltration:  the 
membranous  region  takes  on  a  grayish  red,  slightly  yello"v\dsh  color,  its 
brilliant  luster  disappears  and  gives  place  to  a  dry  and  dull  appear- 
ance. The  epithelium  desquamates  freely  so  that  it  may  be  denuded 
over  a  very  considerable  extent:  it  is  this  more  or  less  complete  des- 
quamation that  is  responsible  for  the  bleeding  which  is  so  easily  pro- 
duced by  the  introduction  of  the  urethroscope. 

The  mucous  folds  which  are  normally  so  numerous  in  the  mem- 
branous region,  disappear  almost  com^Dletely  under  the  influence  of  fi- 
brous infiltration.  "When  this  is  very  nmeli  pronounced,  it  is  no  longer 
possible  to  see  anything  except  a  rigid  tube  of  yellowish  or  jDcaii  Avhite 
color.  Wlien  the  latter  tint  predominates,  it  is  an  indication  of  the 
presence  of  pachydermia  of  the  nmcosa. 

Vegetations  and  polypi  are  frequently  situated  either  on  the  veru- 
montanum or  in  some  portion  of  the  posterior  urethra.  Xot  infre- 
quently their  existence  coincides  with  neurasthenic  j)henomena  of  an 


URETHROSCOPY   OF    XORMAL   AXD   PATHOLOGIC    URETHRA  107 

extremely  marked  type.  Sometimes  they  are  on  tlio  verumontaiium  it- 
self (Fig.  70).  In  this  particular  case,  it  appeared  in  the  form  of  a 
cock's  comh  and  it  was  not  at  all  difficult  to  cause  its  disappearance 


Fig.   70. — Polypus    on   the   summit   of   the   verumontanum. 

with  the  galvanocautery  point.     In  other  cases,  they  take  on  tlie  ap- 
pearance of  long  polypi  resembling  eels   (Fig.  71).     They  may  then 


Fig.   71. — Long  eel-shaped   polypus    on   the   anterior   aspect   of    the   verumontanum. 

assume  the  most  fantastic  forms  according  to  the  way  they  are  made  to 
move  in  one  direction  or  another  under  the  influence  of  the  i^resence  of 
the  urethroscope.     [This  is  beautifully  shown  in  the  modern  water- 


108  CYSTOSCOPY   AND   UKETHEOSCOPY 

dilating  urethroscopes.  The  current  of  water  striking  the  long,  slender 
polypus,  carries  it  along  in  the  direction  of  the  bladder,  and  when  the 
flow  of  water  is  stopped,  it  returns  to  its  normal  iDosition.  Intermit- 
tently making  and  breaking  the  flow  of  water  gives  an  unusually  strik- 
ing picture. — Editor.]  The  phallus-shaped  polypus  shown  in  Fig.  72, 
gives  a  good  idea  of  the  form  they  can  assume. 

Occasionally  they  lie  in  the  membranous  region,  or  they  are  pedun- 
culated, with  a  long  stem.  Or  they  may  take  on  a  cauliflower  appear- 
ance invading  almost  the  entire  posterior  urethra  and  covering  the 
veruniontanum  completely.  These  cases  are  the  most  difficult  to  treat 
because  of  the  extensive  cauterization  which  they  necessitate,  at  the 
same  time  taking  precautions  to  preserve  the  ejaculatory  ducts  intact. 


Fig.   72. — lyOng   phallus-shaped    polyp    on    the    superior    aspect    of    the    veruniontanum. 

I  have  had  the  .opportunity  to  observe  a  similar  case  in  a  young 
man  of  thirty-five,  Avho  presented  frequent  gonococcal  relapses.  The 
center  of  infection  was  in  the  posterior  urethra  which  was  completely 
invaded  with  raspberry-like  vegetations.  Notwithstanding  systematic 
dilatations  of  the  posterior  urethra  with  Franck's  dilator  up  to  No.  45, 
relapses  still  continued  to  occur.  Urethroscopic  treatment  Avas  then 
applied.  It  consisted  of  applications  of  the  actual  cautery  to  the  entire 
posterior  urethra;  these  cauterizations  could  not  be  made  without  di- 
rectly attacking  and  destroying  the  veruniontanum,  thus  leaving  the 
ejaculatory  ducts  exposed.  This  is  well  shown  in  Plate  V,  Fig.  3.  The 
veruniontanum  no  longer  exists  and  the  ejaculatory  ducts  look  like  two 
gun  barrels  fastened  to  each  other. 


URETHROSCOPY    OF    NORMAL    AND    PATHOLOGIC    URETHRA  109 

The  orifice  of  the  prostatic  utricle  is  often  widely  dilated  and  the 
seminal  fhiid  may  be  seen  exuding  from  its  lumen.  In  certain  cases 
when  it  is  necessary  to  estal)lish  the  differential  diagnosis  between 
prostatic  and  vesicular  secretion,  urethroscoi3y  may  l)e  conil)ined  witli 
massage  of  the  prostate,  to  great  advantage.  By  this  means,  seminal 
fluid  can  be  made  to  exude  from  the  prostatic  utricle  and  the  pros- 
tatic ducts  under  the  observer's  eye;  in  this  way,  extremely  useful  data 
may  be  revealed  wdiich  will  often  indicate  the  most  suitable  and  effec- 
tive therapy. 

Occasionally  the  prostatic  utricle  is  shifted  to  one  side  or  another 
of  the  verumontanum  instead  of  occupying  the  median  line;  and  in 
cases  of  chronic  ex)ididymitis  it  is  not  unusual  to  observe  a  purulent 
secretion  emanating  from  the  prostatic  utricle.  Again,  the  lips  of  the 
utricle  may  be  congested  and  verrucous,  and  will  bleed  at  the  slightest 
irritation;  this  condition  explains  one  of  the  symptoms  of  which  pa- 
tients with  chronic  posterior  urethritis  often  complain;  namely,  blood- 
stained seminal  ejaculations. 

When  the  verumontanum  has  been  invaded  by  fibrous  tissue,  it 
becomes  yellowish  in  color  and  appears  as  if  it  were  dried  up  and  rum- 
pled. In  these  cases,  the  orifice  of  the  prostatic  utricle  and  the  ejacu- 
latory  ducts  may  be  contracted  or  entirely  choked  up.  These  lesions 
account  for  the  sharp  pain  at  the  moment  of  ejaculation,  wliich  is  so 
pathognomonic  of  certain  cases  of  cJironic  prostatitis.  In  other  in- 
stances, we  encounter  simple  hypertrophy  of  the  verumontanum,  wdiich 
is  usually  associated  with  the  habit  of  masturbation.  For  a  view  of 
the  "masturbator's  verumontanum"  see  Fig.  73.  This  j)icture  is  so 
true  that  I  have  very  often  been  able  to  accuse  certain  jDatients  of  mas- 
turbation wdio  confessed  the  practice  of  this  habit  only  when  confronted 
with  the  existing  lesion.  In  these  cases  there  is  a  considerable  hyper- 
trophy of  the  verumontanum  which  gives  it  an  appearance  resembling 
the  uterine  neck  involved  in  metritis.  The  utricle  becomes  wide  and 
gaping,  and  takes  on  the  aspect  of  the  mouth  of  a  tench.  The  veru- 
montanum and  the  ejaculatory  ducts  may  undergo  otlier  and  more 
varied  changes;  these  are  studied  in  detail  further  on  (see  Catheter- 
ization of  the  Ejaculatory  Ducts,  page  115). 

Posterior  urethroscopy  is  also  extremely  useful  and  interesting  in 
prostatic  hypertrophy.  In  this  condition,  most  exact  information  can 
be  derived  concerning  the  length  of  the  prostatic  tunnel,  of  the  shape 
of  its  walls  and  of  all  its  sinuosities ;  also  of  all  the  abnormal  protuber- 
ances that  may  be  encountered;  the  latter  being  responsible  for  the 
urinary  difficulties  that  the  patient  complains  of. 

It  can  also  be  seen  how  it  is  possible  to  destroy  these  projections. 


110  CYSTOSCOPY   AND    URETHROSCOPY 

which  prevent  normal  micturition,  under  control  of  the  eye.  Its  thera- 
peutic value  in  these  conditions  can  also  be  appreciated.  Let  it  be  un- 
derstood, of  course,  that  one  can  not  dream  of  supplanting  tralrisvesical 
prostatectomy  in  this  manner;  but  it  is  nevertheless  true  that  this 
method  can  be  of  distinct  service  in  many  cases.    Undoubtedly  it  is  far 


Fig.    73. — Hypertrophied    verumontanum,    the  result   of    a    chronic    inflammation.      The    organ    resembles    the 
uterine   neck.      (Masturbator's   verumontanum.) 

superior  to  the  blind  section  emj^loyed  in  the  Bottini  method,  since  it 
permits  the  cauterization  of  the  exuberant  portions  of  the  prostate  to 
be  done  directly  under  the  control  of  the  eye  (see  Urethroscopic  Treat- 
ment of  Prostatic  Hypertroi^hy,  page  135). 

EEPERENCES 

iWolbarst :     Colliculitis,  or  Disease  of  the  Verumontanum,  Med.  Rec,  New  York,  Oct.  4,  1913 ; 

The  Oollieulus  Considered  as  a  Factor  in  Chronic  Disease  of  the   Male  Urethra,  Am. 

Jour.  Surg.,  October,  1914;  Ann.  Surg.,  October,  1915,  p.  477. 
sDesvignes:      De  la  neeessite   de   I'uretroscopie    dans   le   diagnostic   de   I'uretrite  posterieure 

chronique,  La  Clinique,  1911. 

Urethroscopy  in  the  Female 

Urethroscopy  in  the  female  is  just  as  necessary  as  it  is  in  the  male. 
It  goes  without  saying  that  this  examination  shall  not  be  made  in 
either  sex  without  the  urethra  having  been  sufficiently  dilated  pre- 
viously. In  the  female,  a  short  urethroscopic  tube  should  be  used;  this 
has  already  been  described  (see  page  43). 

However,  as  there  are  numerous  instances  in  Avhich  the  vesical 


URETHROSCOPY   OF    NORMAL   AND    PATHOLOGIC    URETHRA 


111 


iiock  in  tlio  femaiG  also  particiiDates  in  clii-oiiic  iiiflanniiation  of  tlio 
nretlira,  it  is  often  advisable  to  examine  tlie  l)la<l<ler  neck  and  the 
deei^er  portion  of  the  urethra  at  the  same  time.  But  when  the  simple 
iiretlu'oscopic  tube  enters  the  bladder  the  fjresenee  of  tlie  urine  prevents 
a  clear  view  of  the  lesions  existing  at  the  vesical  neck;  consequently 
a  special  instrument  is  necessary  and  I  recommend  for  this  purpose 
the  female  model  of  my  direct  vision  cystoscopy 

Whether  we  employ  the  simple  tube  or  the  direct  vision  cysto- 
scope,  the  entire  urethra  must  be  examined  from  the  neck  of  the  bladder 
to  the  urinary  meatus.  During  the  passage  of  the  instrument  from 
behind  forward,  toward  the  meatus,  it  will  be  possible  to  study  care- 
fully all  the  peculiarities  of  the  mucosa, — the  little  polypi,  the  papil- 
lomata,  and  the  orifices  of  the  urethral  glands. 


Fig.   74. — IvUys'    direct   vision    cystoscopc,    female    model,    complete. 


The  vesical  neck  of  the  female  deserves  quite  special  attention. 
It  should  be  examined  with  the  direct  vision  cystoscope,  both  on  its 
vesical  side  as  well  as  on  its  urethral  aspect.  Important  lesions  may 
thus  be  found  of  which  we  might  otherwise  remain  in  complete 
ignorance,  and  the  disorders  which  they  give  rise  to  would  continue 
indefinitely  with  their  causes  undiscovered. 

At  times,  Ave  find  well-developed  polyi^i,  such  as  are  shown  in 
Plate  XVII.  In  this  particular  case,  the  patient  was  referred  to  me 
with  the  diagnosis  of  bladder  tumor.  Though  her  urine  contained 
l)lood,  cystoscopy  demonstrated  positively  that  she  had  no  tumor  in 
tlie  bladder.  However,  she  did  have  several  small  polypi  at  the  vesical 
neck,  which  clearly  explained  the  bloody  urine. 


112 


CYSTOSCOPY    AXD    UEETHEOSCOPY 


These  polypi  may  exist  only  in  rude  outline.  In  Plate  XX.,  Fig.  1, 
the  cervical  mucosa  can  be  seen  extremely  congested  with  projecting 
areas  of  congestive  edema,  which  seemed  as  if  it  Avould  eventuftlly  end 
in  the  production  of  iDolypi. 

Occasionally  real  abscesses,  not  very  large,  can  also  be  seen  at 
the  vesical  neck;  these  abscesses  may  be  the  cause  of  the  repeated 
urethral  reinfections  so  often  encountered.  In  Plate  XX.,  Fig.  2,  a 
rather  large  abscess  can  be  observed  situated  on  the  urethral  aspect 


Fig.   75. — Large   pediculated   polypvis    in    tlie    female    urethra,    implanted    on    the    floor    of   the    urethra. 

of  the  vesical  neck.  The  young  woman  who  had  this  lesion  suffered 
from  continued  relaiDsing  attacks  of  urethritis  which  could  not  be 
explained  by  the  appearance  of  the  anterior  part  of  her  urethra.  This 
abscess,  which  had  resisted  urethral  dilatation,  was  opened  by  means 
of  the  galvanocautery.  The  cautery  point  first  ruiDtured  the  abscess 
wall;  this  brought  forth  a  flow  of  pus  and  then  completely  destroyed 
the  entire  purulent  pocket  and  resulted  in  a  complete  cure  of  the  patient. 
In  the  female  urethra,  two  cpiite  distinct  anatomic  parts  should  be 


TTlETTTPXiSforV    or    XOr.A.IAL    AX' I    r.\T  ]]()]. nciC    rRETTTRA  113 

(listiiiuiiisliod:  P'ii'>t.  llic  ])osici'i()i'  jxiiiioii  wliicli  adjoin.'?  the  neck  of 
IIm'  l)la(l(ler  and  is  entirely  niuseular  in  structure.  In  this:  portion 
uretliroscop}'  slioAvs  the  presence  of  abundant  muscle  fibers  which  are 
indicated  hy  the  presence  of  regular,  well-marked  radiations.  This 
])ait  of  l]i('  uiollna  is  less  frequently  attacked  l)y  inflammatory  proc- 
esses, lor  it  is  almost  devoid  of  glands.  Secondly,  the  anterior  portion 
of  the  urethra  is  very  diiferent  from  the  posterior  portion  be- 
cause of  the  abundance  of  glandular  orifices.  These  glands  are 
constant  and  constitute  two  important  lateral  groups.  Anatomically, 
they  are  mucous  glands  and  they  open  on  the  surface  of  the  urethra 
l)y  means  of  rather  well-developed  orifices,  which  can  be  seen  plainly 
with  the  urethroscope.  These  glandular  orifices  strongly  simulate  the 
glands  in  the  male  penile  urethra  in  appearance  and  structure,  being- 
homologous  with  the  glands  of  Littre  and  the  lacunae  of  Morgagni. 
Like  the  latter  they  are  liable  to  gonorrheal  inflammation  with  all  its 
consequences.  The  existence  of  these  glands  is  probably  responsible 
for  the  tendency  of  the  gonococcal  infection  to  joersist  in  the  female 
urethra;  they  may  also  account  for  the  frequent  development  of  polypi 
at  the  external  orifice  of  the  urethra  (Fig.  75). 

The  logical  conclusion  to  be  drawn  from  these  data  is  that  the 
]nost  satisfactory  treatment  of  chronic  gonorrheal  urethritis  in  the 
female  is  identically  the  same  as  that  in  the  male;  namely,  dilatation. 

The  necessity  of  urethroscopy  in  the  female  forces  itself  upon  ns, 
for  this  method  of  examination  alone  i^ermits  us  to  make  the  most 
surprising  diagnoses,  which  would  otherwise  be  absolutely  impossible. 

The  following  report  will  illustrate  this  more  fully: 

A  woman,  forty-four  years  of  age,  was  referred  to  me  on  June  o,  1905,  by  Terrier. 
She  said  she  had  been  operated  upon  five  years  previously,  for  a  tumor  of  the  bladder;  the 
urine  was  clear  and  there  was  no  increased  frequency,  but  she  suffered  intense  pain  during 
and  after  the  act  of  urination. 

In  the  belief  that  the  vesical  tumor  had  recurred,  the  patient  had  several  times  visited 
Albarran,  who  had  operated  on  her,  but  he  declared,  after  examination,  that  he  found  no 
lesion  whatever  in  the  bladder.     Then  she  consulted  Terrier,  who  sent  her  to  me. 

Clinically  the  bladder  showed  nothing  abnormal ;  its  capacity  was  over  300  c.c.  The 
vesical  wall  was  entirely  normal  and  painless  to  the  touch.  Further  examination  with  the 
prismatic  (indirect)  cystoscope  proved  tliat  the  organ  was  alisolutely  normal  and  that  there 
was  no  recurrence  of  the  tumor. 

On  June  2?,  I  made  another  examination  witli  my  direct  vision  cystoscope,  and  I  again 
noted  that  the  bladder  appeared  normal.  I  was  preparing  to  suspend  the  examination  and 
was  slowly  withdrawing  the  instrument  which  was  still  in  the  urethral  canal,  when  the  lumen 
of  the  tube  was  suddenly  and  completely  inundated  with  a  muddy  liquid  Avliich  was  ap- 
parently purulent.  After  this  fluid  was  evacuated  and  the  mucosa  dried,  I  inspected  the 
urethral  wall.  I  found  that  there  was  an  orifice  on  the  right  lateral  wall,  about  two  centi- 
meters from  the  meatus,  which  led  into  a  paraurethral  cavity.  Pressure  exerted  by  the  cysto- 
scopic  tube  on  this  cavity,  brought  forth  a  muddy  liquid  accomiianied  by  purulent  clots.     In 


114  CYSTOSCOPY   AE-D    URETHROSCOPY 

this   case,   we   were  undoubtedly  dealing  with   a  paraurethral   abscess,   which  had  been   rup- 
tured by  the  pressure  of  the  cystoscopic  tube. 

Subsequently  the  bottom  of  the  cavity  was  cauterized  with  a  fine  silver  nitrate  pencil 
and  the  paraurethral  orifice  enlarged  with  a  thin  galvanocautery  point  so  as  to  provide  better 
drainage.  Under  the  influence  of  this  treatment,  the  patient's  pains  ceased  and  disappeared 
entirely. 

The  following  is  another  illustration  of  the  great  importance  of 
urethroscojoy  in  the  diagnosis  of  nrethroc^^stic  affections  in  the  female : 

A  woman  was  referred  to  me  in  October,  1910,  complaining  of  severe  pain  in  the  blad- 
der and  urethra  both  during  and  after  micturition,  for  a  period  of  seven  months.  The  pre- 
liminary examinations  were  rendered  very  difficult  owing  to  the  extreme  sensitiveness  of  the 
urethral  canal;  but  with  a  little  patience,  systematic  dilatation  of  the  canal  was  accomplished, 
so  that  the  urethra  was  sufficiently  dilated  by  the  end  of  November  to  enable  me  to  introduce 
my  direct  vision  cystoscope. 

On  November  22,  I  found  that  the  entire  bladder  was  perfectly  normal;  likewise  the 
posterior  portion  of  the  urethra.  But  in  withdrawing  the  tube  slowly  I  noticed  a  little 
edematous  orifice  on  the  left  lateral  wall  through  which  some  drops  of  pus  were  exuding. 
Catheterization  of  this  orifice  with  a  fine  wire  was  j)ractically  imjiossible.  The  lesion  was 
undoubtedly  a  paraurethral  fistula. 

Later  on,  this  orifice  was  enlarged  by  the  galvanocautery,  thus  facilitating  evacuation 
of  the  pus.  A  few  days  after  this  treatment,  the  patient  passed  large  masses  of  purulent 
clots,  which,  on  analysis  by  Hallion,  consisted  of  pus,  and  numerous  ill-defined  bacterial 
forms ;  the  gonococcus  and  Koch 's  bacillus  were  not  found. 


CHAPTER  III 
PRACTICAL  APPLICATIONS  OF  URETHROSCOPY 

ITretliroscopy  is  not  liiiiitod  in  its  usefulness  to  the  examination  of 
the  urethral  mucosa.  Its  field  of  application  has  become  greatly  ex- 
tended so  that  it  is  today  considered  of  the  greatest  value  in  the  diag- 
nosis of  conditions  involving  the  urethra  and  its  adnexa,  especially 
tlie  prostate,  seminal  vesicles,  and  Littre's  glands;  it  has  likewise 
proved  its  great  value  in  a  surprisingly  efficacious  manner  in  the  therapy 
of  these  organs,  particularly  of  the  seminal  vesicles  and  the  prostate. 

We  shall,  therefore,  take  up  in  succession,  first,  catheterization  of 
the  ejaculatory  ducts,  and  second,  the  endourethral  treatment  of  pros- 
tatic hyx^ertrojDln^ 

CATHETERIZATION  OF  THE  EJACULATORY  DUCTS 

When  we  consider  the  astonishing  facility  Avith  which  we  catheter- 
ize  the  ureters  today,  thanks  to  the  perfection  in  modern  technic,  it 
is  surprising  indeed  that  Ave  have  not  made  similar  advances  in  the 
catheterization  of  the  ejaculatory  ducts;  yet  notwithstanding  this 
failure,  medical  literature  is  practically  silent  on  this  subject. 

In  1905  Klotz^  made  several  attempts  to  catheterize  the  ducts. 
He  devised  a  little  special  syringe  provided  Avith  a  fine  cannula  Avliich 
he  introduced  into  the  orifice  of  the  ducts  hoping  thereby  to  inject 
solutions  into  the  seminal  vesicles,  but  the  results  Avere  not  satisfactory, 
inasmuch  as  his  injection  Avas  folloAved  by  epididymitis.  This  attempt 
of  Klotz,  hoAvcA^er,  marked  a  neAv  era  in  this  Avork;  for  it  gaA^e  the 
first  promise  of  a  means  of-  access  toAvard  the  dark  and  mysterious 
sinuosities  of  the  seminal  vesicles.  Undoubtedly  the  solution  of  this 
subject  Avill  be  found  in  the  further  perfection  of  the  technic  of  ure- 
throscopy. 

Belfield-  also  succeeded  in  catheterizing  the  ducts.  But  Avhen  he 
found  the  search  for  these  orifices  rather  difficult  especially  in  patho- 
logic cases,  he  resorted  to  rather  complicated  expedients  in  order  to 
make  the  orifices  of  the  ejaculatory  ducts  more  easily  discernible.  By 
means  of  a  puncture  in  the  A^as  deferens  near  the  groin,  he  injected 
some  milk  Avith  Avhich  he  filled  the  corresponding  seminal  vesicle. 
Subsequently,  by  making  pressure  on  the  milk-filled  A'esicle  through 

115 


116 


CYSTOSCOPY   AND    I^RETHEOSCOPY 


tlie  rectum,  lie  was  able  to  obtain  a  better  view  of  tlie  ejaculatory 
orifices  and  tlms  succeedetl  in  catlieterizing  them.  This  method  was 
not  only  complicated,  but  also  not  without  its  dangers.  ^ 

However,  it  may  be  stated  that  catheterization  of  the  ducts  is  not 
only  possible,  but  absolutely  demanded  in  certain  cases. 

Anatomic  Considerations 

If  researches  on  the  cadaver  are  to  be  taken  as  our  guide  in 
the  study  of  catheterization  of  the  ducts,  we  are  apt  to  be  disappointed 
in  the  results  olitained.  In  the  cadaver,  the  verumontanum  and  the 
ejaculatory  canals  are  certainly  much  more  difficult  to  locate  than  in 
the  living  subject.     This  is  due  to  the  fact  that  the  verumontanum 


|v.-     --^^f-'. 


Ik 


Fig.    76. — Classic    arrangement    of    the    ejaculatory    canals,    situated    symmetrically    on    either    side    of    the 

verumontanum. 


being  essentially  an  erectile  organ,  is  normally  very  vascular  and  filled 
with  blood,  and  in  the  cadaver  is  much  reduced  in  size;  consecjuently 
the  duct  orifices  are  much  more  difficult  to  find.  This  difficulty  of 
catheterization  in  the  cadaver  is  true  of  all  body  canals,  and  particu- 
larly so  as  regards  the  ejaculatory  ducts. 

The  best  way  to  recognize  the  ejaculatory  ducts  is  to  inject  a  little 
water  into  the  lumen  of  the  vas  deferens;  then  on  massage  of  the 
vesicle,  the  urethroscope  in  situ,  we  can  see  the  fluid  entering  the 
urethral  canal  in  the  form  of  a  fine  jet,  and  this  enables  us  to  identify 
the  corresjDonding  duct  and  thereby  note  its  exact  position. 

In  cooperation  with  Pelletier,  we  instituted  a  series  of  urethro- 
scopic  experiments  on  the  cadaver  and  on  a  living  subject,  to  determine 


CATHETEIMZATIOX    OF    E.IACULATOKY    DUCTS 


117 


tlic  ari';iii,i;ciii('iil  of  the  ("jaciihilory  (liicls  in  i-elalioii  to  the  i)roslatie 
utricle  ami  llic  Ncniiiioiiiaiiiiiii.  'I'lic  conclusions  Ave  arrived  at  differ 
considerably  from  the  usual  anatomic  conception.  In  ])oint  of  fact, 
autliors  usually  dcscrihc  tlie  oi-ilices  as  Ixun.ii,-  situated  most  frequently 


Fig.   n . — \'erumontanum    wilhout    any    visible    orifice. 


on  tlie  sides  of  the  yerumontanum  and  symmetrical  with  the  utricle. 
The  Yerumontanum  is  then  found  to  contain  three  openings:  The 
prostatic  utricle  in  the  median  line,  and  the  ejaculatory  orifices  on 
either  side  (Fig.  76). 


Fig.   78. — Ejaculatory   canals   opening   on   the   lips   of   the    prostatic    utricle. 

Tliis  clinical  descrii)tion  is  far  rroiii  correct  in  the  vast  majority 
of  cases.  In  eleven  cadavers  which  we  studied,  this  arrangement  was 
met  with  only  three  times.    In  fact  there  are  cases,  rare  it  is  true,  in 


118 


CYSTOSCOPY   AND    URETHROSCOPY 


wMcli  it  is  not  possible  to  see  any  orifices  at  all,  neither  the  prostatic 
utricle  nor  the  duct  orifices  being  visible.  But  these  instances  are 
almost  always  pathologic  in  character.  '*' 


Fig.   79. — No  prostatic  utricle  visible;   the  ejaculatory  CEiials  open  on  the  lateral  walls  of  the  verumontanmn, 

resembling  a   diver's   helmet. 

A  second  disposition  of  the  orifices  which  is  quite  frequent,  is  that 
in  which  a  median  utricle  is  seen,  and  on  its  lips  or  edges  are  the  orifices 
of  the  ducts  (Fig.  78).     This  arrangement  was  noted  seven  times  in 


Fig.   SO. — The    ejaculatory    canals    open    on    the    lateral    walls    of   the    verumontanum    but    at    different    levels. 


our  study  of  the  cadaver.     Still  another  arrangement  is  that  in  which 
there  exists  no  median  utricle,  but  the  ejaculatory  ducts  open  on  the 


CATHETEIIIZATION'    OF    E.I  ACl'I  ,AT011Y    DUCTS 


119 


lateral  walls  of  the  veniinontaiiiuii  (Fig.  79).  This  is  the  "diver's 
helmet"  appearance,  which  I  have  already  described.'^  In  this  type, 
the  duct  orifices  are  usually  placed  symmetrically  on  cither  side  of 
the  median  lin^there  are  instances,  however,  in  which  they  are  not 
on  the  same  horizontal  plane,  hut  one  lower  than  the  other  (Pig.  80). 


Fig.   81. — Urethroscopic  view  in  which  the  prostatic  utricle  is  visible;   the  ejaculatory  canals  can  not  be  seen. 

The  ejaculatory  ducts  may  be  altogether  invisible  in  another  type. 
The  median  utricle  can  be  seen,  however,  and  it  is  only  wdien  an  inci- 
sion is  made  above  and  below  it,  that  the  ducts  Avill  be  found  at  the 


Fig.  82. — The   ejaculatory   canals   were    made   visible   only    aflcr    incision    of   the    utricle;    they    were    found 

at  the  base  of  the   utricle. 


bottom  of  the  utricle,  lying  close  to  one  another  like  two  gun  l)arrels 
(Fig.  82).  This  arrangement  was  encountered  but  once  in  the  eleven 
cadavers  studied. 

Lastly,  there  is  the  type,  very  rare  indeed,  in  which  the  verumon- 


120  CYSTOSCOPY    AND    URETHROSCOPY 

taimm  is  destroyed  tlirongli  cauterization  witii  silver  nitrate  or  the 
galvanocautery.  Tlie  walls  of  the  organ  disappear  and  helow  them 
nothing  remains  but  the  two  ejaculatory  canals,  fastened  togetlTer  like 
gun  barrels  (Fig.  83).  This  occurs  in  cases  in  which  the  destruction 
of  the  verumontanum  has  been  made  necessary  by  the  persistence  of 
the  gonococcus  in  the  walls  of  the  verumontanum. 

In  conclusion,  we  ma}^  say  there  are  two  princii3al  types:  In  the 
most  common  type,  the  ejaculatory  ducts  open  upon  the  lips  of  the 
utricle;  the  other  is  the  classic  type  above  referred  to;  namely,  the 
median  utricle  and  lateral  orifices.  All  other  types  are  anomalies, 
but  it  should  be  borne  in  mind  that  they  are  quite  common,  nevertheless. 

It  is  interesting  to  note  that  a  catheter  introduced  into  the  ejacu- 


Fig.   83.— Gun-barrel  aspect   of  the   ejaculatory   canals. 

latory  ducts  will  alwa^^s  pass  into  the  seminal  vesicle  and  never  into 
the  vas  deferens.  This  observation  is  confirmed  l3y  our  studies  on  the 
cadaver,  and  is  of  considerable  importance  since  it  is  a  useful  aid  in 
securing  direct  drainage  of  the  seminal  vesicles.  It  is,  therefore,  quite 
probable  that  the  successful  catheterization  of  the  ejaculatory  ducts 
will  bring  with  it  an  effective  means  of  drainage  of  the  seminal  vesicles. 

REFEREl<rCES 

iKlotz:     New  York  Med.  Jour.,  Jau.  26,  1895. 

sBelfield:     Catheterization  of  the  Ejaculatory  Ducts,  Section  on  Genitouriuaiy  Diseases,  Jour. 

Am.  Med.  Assn.,  1912,  p.  24. 
sLuys:     La  Clinique,  Feb.  14,  1913,  No.  7,  p.  98. 


CATHETERIZATION    OF    E.7 AGQLATOIIY    DUCTS  121 

Indications  for  Catheterization  of  the  Ejaculatory  Ducts 

Catheterization  of  the  ejaculatory  ducts  is  demanded  ivhenever 
there  are  disturbances  in  the  function  of  seminal  ejactdation  and  gen- 
erally speaking,  in  all  cases  of  chronic  spermatocy stitis . 

In  point  of  fact,  catheterization  ought  to  be  an  indispensable  fea- 
ture in  tlie  treatment  of  spermatocystitis.  In  this  condition  the  infected 
seminal  vesicles  have  to  be  treated  in  the  most  thorough  manner  from 
one  end  to  the  other;  that  is  to  say,  by  massage  of  the  body  of  tlie  ves- 
icle as  well  as  by  dilatation  of  its  excretory  duct.  Dilatation  is  the  in- 
dispensable complement  of  the  massage,  which  empties  and  expresses 
the  vesicular  contents,  while  the  dilatation  facilitates  and  insures  this 
desired  effect. 

It  is  well  to  remember  the  frequency  of  chronic  spermatocystitis 
in  gonorrhea,  and  on  the  other  hand,  the  ease  A\dth  Avhich  this  pathologic 
condition  remains  latent  for  a  very  long  period.  These  lesions  are  not 
only  unknown  to  the  patient,  w^ho  feels  no  pain  in  or  near  the  infected 
parts,  but  also  to  the  physician  Avhose  attention  is  not  sufficiently  at- 
tracted to  its  possible  existence.  It  is  indeed  extraordinary,  that  well- 
informed  physicians  who  are  familiar  with  the  genitourinary  organs 
so  often  examine  the  prostate  but  utterly  neglect  the  seminal  vesicles 
which  are  far  more  important. 

The  predominating  factor  favoring  the  localization  of  cbronic  in- 
fection in  the  seminal  vesicles  is  the  complete  absence  of  all  spontaneous 
pain  and  the  paucity  of  symptoms.  This  focus  of  infection  must  be 
investigated  thoroughly  again  and  again;  and  in  all  cases  of  urethritis 
which  exhibit  a  tendency  to  last  too  long,  the  best  way  to  recognize  this 
focus  is  by  digital  contact  through  the  rectum.  But  this  is  so  often 
rendered  difficult  by  reason  of  the  inaccessible  situation  of  the  vesicles 
and  the  stoutness  of  the  patient,  that  it  is  necessary  to  place  the  patient 
in  special  positions  in  order  to  examine  the  seminal  vesicles  properly. 
These  little  organs  are  encountered  by  the  examining  finger  in  the 
rectum  when  it  has  passed  above  and  l)eyond  the  lateral  lobes  of  th(^ 
prostate.  But  an  inexperienced  observer  may  very  readily  pass  by  a 
diseased  vesicle  without  recognizing  it. 

There  are  four  principal  diagnostic  signs  l3y  which  we  may  knoAv 
whether  the  seminal  vesicle  is  diseased  or  healthy,  as  follows : 

1.  Pain.  An  infected  seminal  vesicle  is  always  painful  or  tender 
to  the  touch ;  this  sensation  of  pain  must  be  compared  with  the  opposite 
side  to  bring  it  out  more  fully.  Sometimes  it  is  severe  enougli  to  cause 
syncope,  and  it  may  develop  an  immediate  lypotliymia. 

2.  Induration  of  the  walls  of  the  seminal  vesicle. 


PLATE  VI 

Fig.  1. — Prostatic  cavern  ol)served  in  cJironic  prostatitis.  To  the  left  of 
the  picture  the  left  maigiu  of  the  verumontanuin  Avill  be  noted.  Ad- 
jacent to  the  verumontanum  is  the  comparatively  large  mouth  of  the 
prostatic  cavern.  Some  urine  always  accumulated  in  this  pocket.  This 
cavern  always  gave  forth  a  purulent,  urethral  discharge.  It  was  only 
through  a  widening  of  the  mouth  made  by  the  galvanocautery  and  a 
complete  cleansing  with  tincture  of  iodin  that  the  cavity  was  disin- 
fected. 

Fig.  2. — Uretliroscopic  vieio_  of  a  urethral  stricture.  The  mucosa  has 
a  cardboard-like  appearance.  The  urethral  walls  are  invaded  by  fibrous 
tissue;  they  have  no  elasticity  and  can  not  approximate  each  other  at 
the  central  lumen.  They  resemble  a  funnel  of  rather  pronounced  type. 
Littre's  glands,  chronically  inflamed,  are  seen  in  profile  on  the  fibrous 
urethral  walls ;  one  can  also  notice  the  bleeding  clefts  or  cracks  on 
the  wall  which  are  the  results  of  dilatation,  this  having  the  same 
effect  on  the  fibrous  mucosa  as  so  many  little  internal  urethrotomies. 


Fig.  1. 


Fig.  2. 

PLATE  VI 


CATIIETElll/ATlOX    OK    E.JACULATOUY    DL'CTS 


123 


3.  Vesicular  expression  brjjigs  J'oi-ili   i-allicr  large,  i-ihhoii  sliapcMl 
vesicular  casts  (Fig.  85). 

4.  Sensitiveness  or  pain  in  tlio  r(\<;ioii  of  tlic  verumontaimm,  which 
is  determined  by  the  aid  of  tlie  olivary  bougie.     Wlion  tliis  pain  is 


Fig.   84. — A   stylet   introduced    into    the    orifice    of    the   ejaculatory    canals,    enters    the    seminal    vesicles,    and 

not  the  vas  deferens. 

encountered,  it  is  the  indication  of  a  chronic  painful  infianimation  of 
the  verumontanum  and  not  of  a  peculiar  nervous  or  neurasthenic  con- 
dition as  was  formerly  too  often  believed  to  be  the  case.     This  little 


Fig.   S5. — "X'esicular    casts,"    obtained    by    massage    of    the    seminal    vesicles    (drawn    from    nature). 

organ,  Avhich  is  situated  at  the  mouth  of  the  ejaculatory  ducts,  under- 
goes inllammation  by  the  very  reason  of  its  location,  and  its  pathologic 
involvement  is  almost  always  in  direct  relationship  with  the  coexisting 


124  CYSTOSCOPY  AjSTD   ueetheoscopy 

inflammation  of  the  seminal  vesicles.     Tliis  tenderness  to  tlie  toueli 
might  very  properly  be  termed  the  "nrethrovesicnlar  reflex." 

Apart  from  these  distinct  symptoms  which  make  the  di?rgnosis 
fairly  certain,  there  is  a  series  of  symptoms  which  mnst  also  attract 
attention.     These  are  the  folloAving: 

1.  The  nrine  may  be  turbid  or  clear,  with  shreds  in  the  first  glass, 
or  phosphatic. 

2.  Urinary  disorders,  such  as  dysuria  or  iJoUakiuria;  both  of  wliicli 
may  sometimes  be  confused  with  cystitis. 

3.  Spontaneous  pains  but  always  indefinite  and  vague,  referred 
to  the  perinemn,  testicles,  kichieys,  or  tliighs. 

4.  Eeflex  pains  far  removed  from  the  seat  of  the  lesion,  stick  as 
sciatic  neuralgias,  or  renal  pseudocolic. 

5.  Genital  disturbances  characterized  by  painful  ejaculation,  or 
symptoms  of  sexual  weakness  or  nnpotence,  or  finally,  by  an  abnormal 
yellowish  or  bloody  discoloration  of  the  seminal  fluid. 

6.  Eecurrent  epididymitis. 

7.  Most  important  of  all,  indefinite  disturbances,  consisting  of 
general  asthenia  and  complete  body  fatigue.  This  condition  of  fatigue 
disappears  quickly  under  the  influence  of  treatment  for  spermato- 
cystitis  and  patients  soon  recover  their  general  health,  strength,  and 
energy;  the  body  weight  is  also  improved  measurably. 

These  patients  suffer  for  many  years  from  a  sensation  of  heaviness 
in  the  hypogastrium,  dull  pains  in  the  perineum,  in  the  Imnbar  region 
or  the  thighs,  as  well  as  from  scalding  on  urination:  they  also  c-oniplain 
of  a  considerable  decrease  in  sexual  virility  as  well  as  ejaculatory  dis- 
turbances. They  have  a  slight  urethral  oozing  every  morning  and 
shreds  in  the  first  glass  of  uritie.  Usuall^^  they  have  consulted  a  con- 
siderable number  of  physicians,  surgeons,  and  specialists,  and  tlie  result 
of  these  consultations  has  always  been  the  same.  "You  are  a  neuras- 
thenic— a  nervous  person,"  they  say  to  the  patient,  adding  that  there 
is  nothing  the  matter  with  him  and  advise  him  to  pay  no  further 
attention  to  his  troubles,  and  that  they  ^-ill  disappear  of  their  o^mi 
accord  in  due  course  of  time. 

The  result  of  these  persistent  disorders  is  that  tlie  unfortunate 
patient  is  soon  brought  under  the  influence  of  a  j^ermanent  and  irre- 
pressible obsession  with  the  fixed  idea  that  he  is  incurable,  that  lie 
a\t11  never  be  well  again,  that  he  may  never  marry,  and  that  his  life 
is  ruined  forever. 

These  chronic  lesions  terminate  in  a  pitiable  neurasthenic  condition 
which  keeps  the  victim  always  preoccupied  making  life  impossilDle  and 
sometimes  ending  with  suicide.    It  has  been  my  fate  to  have  been  pres- 


CATHETEniZATroX    OF    E.)  ACrLATOltV    DUCTS  125 

('lit  twice  ill  the  role  of  a  ]it'l])lc»ss  spectator  at  a  catastro])li('  of  tliis 
kind.  11  is  a])S()1u1('l\-  necessary  that  the  medical  profession  should 
liave  its  attention  aroused  on  these  matters.  Unfortunately,  too  often 
the  unhappy  patient  presenting  these  symptoms  is  treated  as  nerv- 
ous and  iKMirastlK'iiic,  wlicreas  it  wonhl  he  a  really  simple  mattei- 
to  make  a  methodical  examination  of  the  posterior  urethra,  discover 
the  lesions  and  give  them  ajjpropriate  treatment. 

S.  Jorge  de  (Jouvea,  of  Rio  de  Janeiro  lias  reported^  the  following 
interesting  case  of  sexual  neurasthenia  cured  by  endoscoiw: 

''Sexual  neurasthenia  in  the  male  often  has  its  starting  point  in  a  pathologic  condi- 
tion of  the  posterior  urethra.  These  elironic  lesions,  almost  all  of  gonorrheal  origin,  are 
usually  localized  in  the  verumontanum  which  we  know  enjoys  an  abundant  nerve  supply.  We 
can  therefore  readily  understand  how  it  happens  that  a  pathologic  process  which  gradually 
brings  about  such  exten.<;ive  anatomic  changes,  is  able  to  produce  so  many  local  neiTOus 
disturbances  which  react  on  tlie  general  condition  of  the  patient. 

""Whenever  in  a  neurasthenic,  disturbances  pointing  to  the  urogenital  system  become 
manifest,  it  is  absolutely  necessary  to  have  recourse  to  the  modern  methods  of  examina- 
tion of  the  urinary  apparatus.  Endoscopy  enables  us  to  determine  exactly  the  seat  of  the 
lesion  which  is  giving  rise  to  these  general  disturbances;  likewise  we  are  enabled  to  treat 
the  lesion  in  a  rational  manner  under  control  of  the  eye,  thus  bringing  about  a  cure,  not 
only  of  the  local  lesion,  but  also  an  amelioration  and  even  a  complete  cure  of  the  constitu- 
tional disturbances. 

' '  This  is  what  I  have  been  able  to  report  in  the  following  case  in  which  the  Luys ' 
urethroscope  enabled  me  to  determine  the  cure  of  a  series  of  disorders  which  caused  my 
patient  to  lead  a  life  that  was  liractically  unbearable.  As  soon  as  the  diagTiosis  was  made, 
a  complete  cure  was  readily  obtained,  as  will  be  seen  from  the  following  history: 

"M.  F.,  a  soldier,  forty  years  of  age,  consulted  me  on  July  20,  1910.  He  had  his  first 
gonorrhea  eight  years  previously  and  had  treated  Mmself  with,  injections  of  nitrate  of  silver 
and  sulphate  of  zinc.  He  was  left  with  a  morning  drop  which  almost  disappeared  when 
he  irrigated  the  urethra  with  j)ermanganate,  but  which  became  aggravated  whenever  he  com- 
mitted an  excess  of  any  kind. 

' '  At  the  time  of  the  examination,  he  is  forced  to  urinate  frequently,  small  quantities 
being  passed  each  time.  During  the  act  he  experiences  discomfort  and  a  sensation  of  heat 
which  extends  through  the  urethra  and  the  perineum.  At  the  end  of  urination  he  has  violent 
erections.  Xoeturnal  pollutions  are  rather  frequent  and  the  emissions  in  coitus  are  pre- 
mature and  painful.  He  has  lost  weight  recently,  is  very  nervous,  hypochondriac  and  dis- 
couraged; digestion  is  poor,  and  he  always  has  vague  lumbar  pains.  The  urine  is  clear  with 
filaments  in  the  three  glasses. 

""With  the  bladder  filled  with  a  solution  of  oxycyanide  of  mercury,  I  examined  his  ure- 
thra. At  the  base  of  the  penile  region,  I  found  a  sensitive  stricture  made  evident  by  a  No.  12 
olivary  bougie.  The  posterior  urethra  was  also  distinctly  tender.  The  kidneys  ajjparently 
negative,    chronic   prostatitis,   painful   seminal   vesicles,    Cowper's   glands   negative. 

' '  For  fifteen  days  I  irrigated  him  urothro-vesically,  with  permanganate  and  oxycyanide 
solutions.  This  was  followed  by  internal  urethrotomy  witli  Kollmann's  urethrotome;  no 
retention  sound.  At  the  end  of  four  days  I  began  progressive  dilatation  of  the  anterior 
urethra  with  straight  metallic  sounds  up  to  Xo.  50.  When  I  tried  a  Xo.  51,  it  passed  easily, 
but  on  reaching  the  posterior  urethra,  it  produced  a  sharp  pain  and  gave  rise  to  slight  bleed- 
ing. Some  days  later  I  continued  the  dilatation  after  local  anesthesia  with  novocaine  and 
adrenalin.  The  dilatation  was  slowly  increased  until  Xo.  55  was  reached,  and  then  I  intro- 
duced a  Luys'  urethroscopic  tube  Xo.  55. 

"Examination  of  the  posterior  urethra  sho\\ed  that  the  cause  of  his  illness  lay  in  the 


126  CYSTOSCOPY   AjSTD    UEETHROSCOPY 

Terumontanum,  which  was  swollen  and  covered  with  many  small  raspberry-like  growths  on 
its  surface;  its  base  was  free.  With  a  fine  galvanocautery  point,  I  destroj'ed  these  vegeta- 
tions and  cauterized  the  surface  with  tincture  of  iodiii ;  the  operation  was  repeated  a 
week  later.  During  the  succeeding  month,  I  instituted  a  series  of  prostatic  masSSges  and 
deep  instillations  of  silver  nitrate,  and  the  patient  began  to  show  signs  of  distinct  improve- 
ment. I  continued  the  massage  and  the  endoscopy,  cauterizing  the  verumontanum  with  iodin 
at  each  sitting. 

''At  the  end  of  three  mouths  the  patient  urinated  freely,  and  did  not  complain  any 
longer  of  the  sensations  which  he  formerly  experienced.  The  improvement  was  fully  con- 
firmed with  the  urethroscope.  He  no  longer  had  his  morning  drop,  his  urine  was  normal  and 
he  passed  it  with  normal  freciuency.  I  saw  him  again  six  months  later  and  his  general  con- 
dition was  excellent.     Undoubtedly  the  cure  was  permanent. ' ' 

REFEEENCE 
iDeGouvea:     La  Clinique,  July  19,  1912,  No.  29,  p.  459. 


Treatment  of  Spermatocystitis 

The  oj)erative  treatment  of  si3ermatoc3^stitis  has  been  studied 
chiefly  by  the  Americans.  The  operations  that  have  been  proxjosed 
are  the  following: 

1.  Vesiculotomy  (Drainage  of  the  Vesicle)  proposed  by  Fuller, 
of  New  York.  The  patient  is  jolaced  in  the  gennpectoral  position  and  a 
curved  incision  is  made  in  front  of  the  rectum.  To  avoid  injuring  the 
latter,  Fuller  introduces  the  index  finger  of  the  left  hand  in  the  rectum, 
then  with  the  index  finger  of  the  right  hand  introduced  into  the  Avound 
made  by  a  somewhat  careful  dissection,  he  searches  for  the  space 
situated  between  the  rectum,  prostate  and  seminal  vesicles.  The 
vesicle  having  been  located  with  the  finger,  he  plunges  a  grooved 
director  into  it  and  on  this  he  introduces  a  bistoury.  [The  vesicle  is 
then  drained  for  several  days  with  a  rubber  tube. — Editor.]  This 
operation  is  evidently  done  blindly  and  does  not  conform  to  the  stand- 
ards of  contemporaneous  surgery. 

2.  Vesiculectomy  (Excision  of  the  Vesicle),  which  may  be  done 
either  by  the  inguinal,  perineal,  or  the  ischiorectal  routes.  This  opera- 
tion is  very  difficult  and  involves  considerable  mutilation  and  risk.  It 
is  undoubtedly  unsuitable  in  the  vast  majority  of  cases. 

3.  Vasotomy  (Vasopuncture),  proposed  by  Belfield,  of  Chicago. 
He  exposes  the  vas  deferens  near  the  inguinal  canal,  then  introduces  a 
fine  silver  cannula  into  the  vas,  through  which  he  injects  a  solution 
of  either  argyrol,  j)rotargol,  or  coUargol.  In  this  way  he  maintains 
that  he  succeeds  in  flooding  the  seminal  vesicle  with  the  solution;  he 
injects  daily  for  several  days,  then  removes  the  cannula  and  closes  the 
incision. 

These  surgical  procedures  seem,  in  most  cases,  altogether  out  of 


CATHETEPtTZATFON    OF    EJACULATOin'    DUCTS  ]  27 

proportion  lo  llic  rolaiivc  mildiioss  of  llio  disease,  so  iiiufli  so  llial  lliey 
should  iiol  l)e  resorted  to  except  in  tlie  most  sei-ious  and  desperate 
eases.  Tu  llie  vast  majority  of  cases,  tlie  treatment  of  spermato- 
cystitis  slionld  consist  of  tlie  folloAvinft':  Massai^-e  of  tlie  seminal  vesi- 
cles, local  li'caiiiKMit  of  ilic  ^■('^ulll()ll1alllllll  and  calliclcri/.alion  of  tlic 
])rostatic  utricle  and  of  the  ejaculatory  ducts. 

Massage  of  the  seminal  vesicles  is  difficult  and  takes  time,  and 
must  be  repeated  frequently  for  a  long-  period  of  time.  It  should 
l)e  rememl)ered,  in  this  connection,  that  many  physicians  do  not  usually 
succeed  in  massaging;  the  vesicles  jiroperly,  hut  limit  themselves  to 
the  prostate  or  the  lower  extremity  of  the  vesicle.^  To  massage  or 
strip  the  vesicle  properly  the  top  of  the  vesicular  ciil-de-sac  must  he 
reached  and  stripped  Avith  the  finger  from  above  dov\'nward.  Unless 
this  is  done,  massage  of  the  vesicle  is  practically  useless. 

On  the  other  hand,  though  this  treatment  is  highly  effecti\'e  when 
properly  done,  so  far  as  the  affected  vesicle  is  concerned,  it  is  insuf- 
iicient,  inasmuch  as  it  is  absolutely  essential  to  treat  the  other  ex- 
tremity of  the  vesicle  also,  that  is,  the  ejaculatory  duct  adjacent  to 
the  verumontanum. 

Local  treatment  of  the  vermontanum  should  be  carried  on  under 
the  control  of  the  eye  with  the  aid  of  the  urethroscope.  Unfor- 
tunately at  the  present  time  this  is  c{uite  generall}^  ignored.  The  af- 
fected verumontanum  is  treated  at  frequent  intervals.  Above  all,  it 
is  necessary  to  begin  by  diminishing  the  inflammation  of  the  veru- 
montanum by  means  of  copious  urethrovesical  irrigations  and  dilata- 
tion of  the  posterior  urethra  by  means  of  curved  sounds.  And  when 
dilatation  has  been  carried  far  enough,  so  that  a  fairly  large  ure- 
throscopic  tube  can  be  introduced  without  undue  difficulty,  local  treat- 
ment of  the  verumontanum  should  be  begun.  It  should  consist  pri- 
marily in  caustic  aiDi^lications  to  the  surface  of  the  verumontanum. 

These  direct  applications  are  not  usually  painful  and  never  pro- 
duce that  tenesmus  which  is  so  disagreeable  in  the  case  of  strong  injec- 
tions; whereas  on  the  other  hand,  they  produce  the  most  desirable  and 
happy  results.  Under  their  influence  the  verumontanum  rids  itself  of 
all  the  pathologic  products  which  disfigure  if,  such  as  polyposis,  edema, 
and  ecchymoses.  At  the  end  of  a  certain  period  of  treatment,  the  result 
is  a  perfectly  smooth  and  regular  verimiontanum  with  its  princi]ial 
characteristics  clearly  defined  and  outlined. 

When  this  stage  in  the  improvement  has  been  aitained,  it  is  de- 
sirable to  explore  carefully  the  prostatic  utricle  and  the  ejaculatory 
canals.  Catheterization  of  these  canals  is  necessary  in  the  majority  of 
instances,  absolutely  indispensable  in  many.     The  need  of  catheteriza- 


].28  CYSTOSCOPY   Als^D    URETHROSCOPY 

tion  is  due  to  tlie  fact  that  these  ducts  very  often  undergo  the  same 
pathologic  changes  as  tlie  urethra  in  general,  and  there  is  no  reason 
why  the  duct  walls  should  escape  the  same  fibrous  alterations  that  take 
j)lace  in  the  rest  of  the  urethral  canal. 

Since  strictures  of  the  urethra,  which  are  tlie  result  of  gonorrhea, 
are  more  or  less  frequent,  strictures  of  the  ejaculatory  ducts  must  like- 
wise be  frequent;  and  these  strictures  must  necessarily  exert  consider- 
able influence  on  the  pei'i^etuation  of  chronic  spermatocystitis.  In  point 
of  fact,  because  of  the  inflammation  of  its  walls,  the  seminal  vesicle  is 
filled  with  pathologic  products  which  appear  in  the  form  of  "casts." 
Now,  these  vesicular  casts  have  a  certain  volume  which  makes  it  impos- 
sible for  them  to  pass  through  an  ejaculatory  duct,  the  lumen  of  Avhich 
has  been  narrowed  by  a  stricture. 

Thus  the  evacuation  of  these  gross  jiathologic  products  can  not 
take  place  during  the  seminal  ejaculation.  This  exj^lains  the  fact  ob- 
served in  many  instances,  that  during  or  after  massage  of  the  affected 
vesicle  a  sharp  pain  is  often  experienced,  even  perhaps  an  acute  or- 
chitis; in  these  cases,  there  is  no  evacuation  of  the  i^athologic  products 
as  the  result  of  the  massage.  It  is  in  these  conditions  that  catheteriza- 
tion of  the  ejaculatory  ducts  is  necessary  and  even  indisiDensable.- 

REFERE]SrCES 

iFor  full  details,  see  Luys'  Traite  de  Blenorragie,  Paris,  O.  Doin,  ed.  2,  p.  308. 

-Le  Catlieterisme  des  Canaux  ejaculateurs.  La  Clinique,  Feb.  14,  1913,  No.   7,  p.  98. 

Contraindications  and  Accidents  Incident  to  Catheterization 
of  the  Ejaculatory  Ducts 

The  existence  of  an  acute  inflammation  of  the  urethra  or  of  the 
seminal  vesicles  constitutes  the  most  general  contraindication  to 
catheterization  of  these  ducts.  The  urethra  must  first  be  completely 
cleared  up  before  the  treatment  of  the  ejaculatory  canals  can  be  con- 
sidered. Moreover,  there  should  be  no  active  inflammatory  condition 
either  in  the  seminal  vesicles  or  in  the  posterior  urethra.  If  these 
rules  are  adhered  to,  all  accidents  will  be  avoided. 

In  some  sixty  odd  cases  in  which  I  have  catheterized  the  ducts,  I 
have  never  had  a  single  accident  which  could  be  attributed  to  this  sur- 
gical procedure,  and  it  is  only  because  I  have  always  acted  with  great 
circumspection,  proceeding  to  the  catheterization  of  the  canals  only 
after  having  thoroughly  prepared  and  studied  the  individual  cases. 


CATiiKTKin/A'rio.v  Ml'   ivi Aci '  1  ,.\'i'( )i: ^•   ducts  \2U 

Injection  Into  the  Seminal  Vesicles 

Siiiii)l('  ciiUicU'ri/alion  ol'  llic  cjaculaloi y  duels  is  ^I'cally  to  l)e  pre- 
t'cn-cd  to  llic  injection  of  various  solutions  into  llic  intci-ior  ot  tlie  ves- 
icles. Indeed,  the  cardinal  value  of  cidlielerizalion  of  llie  ducts  lies  in 
(lie  dilatation  of  the  ducts  and  therefore  in  the  iiii])rove(l  drainage 
whicli  it  assures  to  the  inllannnatory  products;  to  this  con-esponding' 
de<;i'ee  it  nmst  he  evident  that  injections  into  the  vesicles  without  this 
ini])roved  di-ainage  must  l)e  liazardous  and  even  danft'erous. 

In  ])oint  of  fact,  it  is  absolutely  impossible,  at  the  present  time,  to 
detei-mine  tlu^  exact  location,  form,  and  dimensions  of  the  seminal 
vesicles,  so  that  it  is  difficult  to  decide  upon  tlie  quantity  of  fluid  that  is 
required  to  fill  the  vesicles  completely.  It,  therefore,  happens  quite 
frequently  that  the  injected  fluid  does  not  escape  from  the  vesicle.  It 
remains  in  the  vesicular  cavity  diluting  and  disseminating  the  infected 
])roducts  without  bringing  about  any  curative  effect.  On  the  contrary, 
the  only  time  that  I  succeeded  in  injecting  any  liquid  with  certainty 
into  a  seminal  vesicle  (it  was  boric  solution),  an  epididymitis  devel- 
oped in  the  corresponding  testicle  two  days  later.  But  strange  to  re- 
late, this  epididymitis  passed  off  rapidly,  without  any  fever  and  almost 
without  i^ain,  the  patient  having  been  made  aware  of  the  inflammation 
only  by  reason  of  the  increased  weight  of  the  testicle. 

The  cavity  of  the  seminal  vesicles  can  in  no  way  be  compared  with 
the  pelvis  of  the  kidney,  the  normal  capacity  of  which  is  usually  the 
same  and  which  is  easily  distended;  when  the  limit  of  distention  is 
]-eaclied  it  is  distinctly  and  instantly  felt  by  the  patient  on  account  of 
tlie  pain  which  immediately  follows. 

Finally,  in  conclusion,  catheterization  of  the  ejaculatory  ducts  is 
the  only  method  to  employ, — it  facilitates  drainage  of  tlie  infected  ves- 
icles, and  it  would  appear  that  an^^  injections  into  the  cavity  of  the 
vesicle  must  not  be  attempted  until  we  are  better  informed  than  we 
ai-e  today. 

[The  editor  assumes  the  liberty  of  supplementing  the  above  re- 
marks by  the  following:  Eecent  improvements  in  technic  have  enabled 
us  to  secure  splendid  radiograms  of  the  seminal  vesicle,  thus  giving 
us  exact  information  as  to  the  size,  shape  and  location  of  the  organ. 
Likewise,  Ave  are  enabled  to  detei-mine  Avhether  the  inj(»cted  fluid  re- 
mains in  the  vesicle  or  passes  through  the  ejaculatory  ducts,  by  the 
simple  expedient  of  injecting  argyrol  or  any  other  colored  fluid  through 
the  vas  deferens,  and  inunediately  thereafter  passing  a  catheter  into 
the  bhulder.  The  colored  (luid  A\ill  be  found  to  have  entered  the  blad- 
der via  the  ejaculatoiy  ducts  and  the  posterior  urethra,  if  the  ducts  are 


130 


CYSTOSCOPY    AND    URETHROSCOPY 


jjatent.  If  the  ducts  are  stenosed,  the  fluid  will  remain  in  the  vesicle 
and  the  bladder  urine  will  not  be  changed  in  color.  If  both  sides  are 
to  be  tested  at  the  same  session,  different  colored  fluids  are  i^ijected, 
and  drawn  off  separately  from  the  bladder.  The  test  is  simple  and  ab- 
solutely reliable. — Editor.] 

Operative  Technic:    Catheterization  of  the  Ejaculatory  Ducts 

The  descrii3tion  and  operative  technic  of  my  urethroscope  having 
been  thoroughly  described  above  (see  page  43)  we  shall  not  return  to 
it  at  present.  For  catheterization  of  the  ducts,  a  thorough  urethro- 
vesical  irrigation  is  given  in  order  to  cleanse  the  urethral  mucosa.  A 
long  tube  13  centimeters  in  length  is  to  be  preferred.  This  tube  Avill 
be  chosen  according  to  the  caliber  of  the  urethra,  the  largest  diameter 
possible  being  selected.  The  tube  is  introduced  directly  into  the  pros- 
tatic fossette  up  to  the  anterior  aspect  of  the  verumontanum.     Several 


Fig.  86. — Metallic    bougies    for    catheterization    of    the    ejaculatory    canals. 

views  may  present  themselves,  and  it  is,  therefore,  fitting  to  refer  to 
the  illustrations  that  have  already  been  mentioned  in  this  connection. 

The  simplest  case  is  that  in  which  there  exists  no  median  pros- 
tatic utricle,  but  on  the  lateral  sides  of  the  verumontanum  on  either 
side  of  the  crest  situated  symmetrically  two  very  distinct  orifices  are 
seen  which  mark  the  lower  extremity  of  the  ejaculatory  ducts.  In  these 
cases  the  verumontanum  presents  an  apjDearance  similar  to  the  diver's 
helmet  (Fig.  79).  It  goes  without  saying  that  catheterization  of  the 
ejaculatory  ducts  in  this  type  of  case  is  comparatively  simple. 

In  catheterization,  a  straight  metallic  stylet  is  preferably  chosen, 
and  of  the  smallest  possible  caliber,  to  begin  with.  The  urethroscope 
is  turned  about  so  that  the  lamp  will  be  above,  and  not  on  the  floor  of 
the  tube.  The  stylet  is  then  directed  horizontally  along  the  entire 
length  of  the  floor  of  the  urethroscopic  tube  and  easily  brought  up  to 
the  orifice  which  is  to  be  catheterized.     The  "button-like"  mouth  of 


CATHETERIZATION"    OF    E.TACULATORY    DUCTS  131 

tlie  orifice  is  tlicii  ix'iicl  rated  hy  llic  stylet  in  a  iiiaTiiier  similar  to  that 
employed  in  calliclci-izalioii  of  llic  urctei'al  oi'iliccs.  Tliis  entrance  is 
facilitated  hy  ('in])l()yin^-  lateral  and  vertical  movements.  The  stylet 
havinft'  entered  llic  orifice  is  inserted  more  deeply,  carefully  and  ft'ently 
penetrating'  from  one  to  two  centimeters  and  even  up  to  six  centimeters 
into  tile  inicrioi-  of  the  ejaculatory  duct.  TC  the  slightest  resistance  is 
encountered,  llie  movement  should  l)e  stop])ed.  If  these  methods  are 
(Muployed,  there  will  usually  be  no  pain  nor  much,  if  any,  bleeding. 

The  first  stylet  having  been  introduced,  a  second,  of  greater  calibei- 
is  employed  in  the  same  manner,  and  so  on  up  to  the  largest  size;  care 
being  always  taken  to  follow  the  rules  of  ureteral  catheterization: 
namely,  avoiding  any  undue  force  or  causing  any  bleeding  of  the 
mucosa. 

When  the  ejaculatory  ducts  can  not  be  detected  and  with  only  a 
single  median  utricle  present,  a  similar  j)rocedure  should  be  adopted. 
The  point  of  the  stylet  is  directed  quite  horizontally,  so  as  to  make  it 
penetrate  directly  into  the  utricle.  Then  the  handle  of  the  stylet  is  in- 
clined (to  the  left  for  the  left  jduct,  to  the  right  for  the  right  duct). 
Then  after  careful  and  gentle  manipulation,  the  orifices  of  the  ejacula- 
tory ducts  will  be  discovered  and  penetrated  as  above  described. 

Results  Achieved  Through  Catheterization  of  the 
Ejaculatory  Ducts 

Ever  since  I  have  adopted  catheterization  of  the  ducts  as  an  in- 
dispensable and  essential  factor  in  the  treatment  of  chronic  spermato- 
cj^stitis,  the  results  in  my  j^ractice  have  been  entirely  satisfactoiy.  In 
these  cases,  the  evacuation  of  the  pathologic  jDroducts  retained  in  the 
vesicles  has  been  accomplished  by  means  of  massage  under  conditions 
of  improved  drainage  which  the  extensive  dilatation  of  the  ejaculatory 
ducts  has  made  possible,  and  the  results  have  been  most  satisfactory. 

The  following  case  is  one  of  the  most  interesting  and  instructive 
that  has  come  under  my  observation,  in  which  catheterization  of  the 
ducts  was  successfully  performed  with  excellent  results: 

The  patient,  M.  G.,  aged  forty  years,  was  lirought  to  mc  ])y  M.  Ilabibollah,  an  extern 
of  the  hospitals  of  Paris.  Tliis  j^atient  had  had  three  attacks  of  gonorrhea,  almost  all  of 
llii'iu  Iieing  accompanied  by  various  complications  whieli  included  prostatitis  and  orchitis. 
^^■hen  he  visited  me  in  August,  1912,  ho  had  an  abundant  discharge  wliich  contained  gono- 
cocci.  His  urine  was  uniformly  turbid  in  all  four  glasses.  Examination  showed  the  exist- 
ciifo  of  a  voi'v  clear-cut  case  of  chronic  prostatitis;  the  opididymes  presented  hard  indurations; 
the  scniinal  vesicles,  especially  the  left,  were  painful   lo  the  1ouch. 

Treatment  consisted  at  first  of  thorough  urctlirovesical  irrigations  with  permanganate 
combined  with  massage  of  the  prostate  and  of  the  seminal  vesicles.     Dilatation  of  the  urethral 


PLATE  yil 

Fig.  1. — Normal  appearance  of  the  urethral  hulh.  TTie  central  figure  takes 
on  the  form  of  a  vertical  cleft;  the  appearance  of  this  region  is  highly 
characteristic. 

Fig.  2. — Pediciilated  polypus  of  the  bulbous  region  seen  through  the  ure- 
throscope. 

Fig.  3. — Enormous  cystic  gland  of  Littre  easily  destroyed  through  vigorous 
dilatations. 

Fig.  4. — Lacuna  of  Morgagni  chronicnlly  inflamed.  Its  comi^lete  disap- 
pearance can  be  secured  only  by  the  application  of  the  electrolytic 
needle  directly  ujjon  it. 

Fig.  5. — Soft  infiltration  of  the  urethra  (typical  urethroscoiaic  aspect). 
The  puifed  up,  oozing  masses  have  an  appearance  similar  to  a  mass  of 
hemorrhoids. 

Fig.  6. — Stricture  of  the  urethra.  This  figure  is  analogous  to  that  of  Plate 
VI,  Fig.  2.  It  shows  also  the  pasteboard-looking  appearance  of  the 
urethral  walls. 


/ 


Fig.  1. 


Fig.  2. 


Fig.  .3. 


Fig.  4. 


Fig. 


PLATE  VII 


Fig.  6. 


CA'I'IIK'I'HUI/A'nox    OK    K.I.\('|■l,A'^o|;^•    Dl'CTS  1  .l.j 

ciiiiiil  \v;is  then  i  list  il  iitnl  :it  lirst  with  cimaciI  shuikIs,  l;itcr  witli  i-'raiK-U's  t  lu'iM'-liniiiclicd 
in  iL;at  iii;^   il  ilatnr. 

Xcvcrlliclcss,  till'  Irfl  vesicle  was  still  extremely  jciiiiful  early  iii  Jaiiuaiy,  JlH.';.  in 
aililitinn,  the  hi'^hly  iiii]H. riant  fact  was  noted,  that  the  contents  of  the  left  seminal  vesicle 
could  imt  lie  evacuated  1  ly  massage  vi<;oirius  eiinii;;li  to  catiso  sevcrc  sharp  pain.  Ono  day 
an  attack  (if  epididymitis  in  tin  hd't  testicle  was  provuked  hy  a  massage,  n<i  instrument  lliat 
nii-lit  liiive  accounted  for  it  haviiii;  lieeii  introduced  into  tin'  urethra.  'riii)Ut,di  tlu-  attack 
ke|it  him  in  lieil  three  or  four  days,  the  reaction  \vas  sli^^ht  and  the  i ntlammation  yielded  to 
treatment  quite  icadily.  This  occurrence,  c(Mul)iiied  with  the  alio\c  noted  oliservation,  clearly 
demoiistrat<'d  that  ma.ssagc  was  ]iot  emptying  the  seiuinal  vesi(de  and  that  in  consequence 
the  ejaculalory  canal  was  undoubtedly  choked  up  with  the  debris.  In  these  circumstances 
it   was  but   natural  that   an  attemjit  be  made  to  i-ecstablish  a  fice  bimen   in  the  duct. 

After  all  evidence  of  intlainmat  ion  in  the  canal  had  d  isa[ipea  reil,  I  made  a  iiretliro- 
scopic  examiiuition  on  January  17,  l!)lo,  with  a  tube  No.  2(3  caliber.  The  verumontanum  was 
easily  visible  and  because  of  the  antecedent  local  treatment  there  was  no  inflammation  or 
bleedinc;. 

The  orifices  of  the  cjaculatory  ducts  were  found  on  the  lateral  sides  of  tJie  verumontanum. 
On  the  left  side,  the  orifice  of  the  corresponding  duct  presented  clearly,  and  I  tried  to  cath- 
(Uerize  it  with  a  fine  urethral  sound  No.  5;  but  the  tip  of  the  stylet  immediately  slipped  on 
<  he  swollen  and  smooth  surface  of  the  verumontanum  and  refused  to  enter  the  interior.  I 
then  took  a  metal  stylet  with  a  studded  tip  and  I  noted  that  its  end  penetrated  the  orifice 
of  the  duct  with  the  greatest  facility.  Tlie  tip,  being  slightly  conical,  was  at  first  arrested 
sonunvhat,  but  it  soon  entered  the  lumen  of  the  duet  for  a  distance  of  about  one  and  a  half 
centimeters. 

Immediately  after  this  catheterization,  the  Idadder  was  filled  with  oxycyanide  solution 
and  the  left  seminal  vesicle  massaged.  To  my  great  surjirise  and  gratification,  I  found  tliat 
massage  hardly  produced  any  pain.  In  additi-on,  I  saw  that  it  was  followed  immediately 
by  the  evacuation  of  enormous  purulent  clots  which  ran  into  the  glass  held  at  the  urinary 
meatus.     Never  before  had  massage  produced  such  an  evacuation  in  this  patient. 

Following  this  procedure,  not  only  was  there  no  untoward  local  reaction,  but  the  hard- 
ened left  epididjTnis  diminished  in  size  and  the  urine  became  normal  and  absolutely  devoid 
of  shreds.  This  improvement  continued,  for  the  patient  remained  in  the  same  satisfactory 
condition  when  I  saw  him  ten   days  later. 

It  seems  then  beyond  any  dou1)t,  that  in  accordance  with  tliis 
oljsei'vation,  catheterization  of  the  ejacuhitory  dncts  may  and  shouhl 
be  advised  when  the  canals  present  a  stenosis  whicli  prevents  tlie  nor- 
mal evacuation  of  the  secretion  products  of  the  seminal  vesicles. 

Catheterization  has  likewise  produced  the  happiest  results  in  dis- 
turbances of  ejaculation  whether  they  have  been  characterized  by  pain, 
or  retardation,  prematurity  or  bleeding. 

I  have  also  had  occasion  to  treat  a  colleague  who  for  years  mani- 
fested the  tenderness  which  I  have  emphasized  above  and  who  also  had 
become  thoroughly  neurasthenic  because  of  the  pains  which  he  suffered 
after  every  coitus.  He  had  a  marked  chronic  ])ostt'rior  uretliriiis  ac- 
companied, as  it  always  is,  with  a  clear  case  of  chronic  spermatocystitis. 

The  ti'eatment  at  lirst  consisted  of  dihdation  of  tlie  nretliia.  This 
was  followed  by  a  thorough  cleansing  of  the  veruiiioiitainini,  l!iii.<  free- 
ing it  of  several  little  polyjDi  and  vegetations.  This  was  accomi)lished 
by  burning  them  with  the  ^-alvanocaiiterv.     The  tr(>atmoiit  culminated 


134  CYSTOSCOPY    A]<rD    URETHROSCOPY 

in  the  catheterization  and  dilatation  of  the  ejaculatory  ducts.  The  last 
step  alone  relieved  him  of  his  suffering.  The  vague  pains,  constant 
and  severe,  which  had  made  his  life  almost  unbearable,  also  *disap- 
peared.  This  was  undoubtedly  a  clear  case  of  stenosis  of  the  ejacula- 
tory ducts.  Indeed  though  the  smallest  metallic  sounds  passed  into 
the  ejaculatory  ducts  quite  easily,  to  the  contrary,  the  larger  sounds 
were  passed  only  through  the  application  of  gentle  force  which  pro- 
duced a  sensation  like  that  produced  in  urethral  stricture. 

In  other  cases,  phenomena  of  delayed  ejaculation  resulting  in  cer- 
tain types  of  sterility  are  sometimes  observed.  A  man  aged  thirty 
years,  married  one  year,  was  referred  to  me,  by  Alexandre,  in  January, 
1914,  the  complaint  being  that  he  was  childless  though  very  anxious  to 
have  a  child.  He  also  comj)lained  of  pain  at  the  moment  of  ejaculation. 
Posterior  urethroscopy  revealed  the  cause  of  his  troubles. 

The  verumontanum  was  much  deformed.  Its  anterior  wall  ap- 
peared eroded,  and  the  prostatic  utricle  projected  forward  so  that  it 
resembled  a  uterine  neck.  This  was  evidently  the  cause  of  his  sterility, 
for  at  emission  there  was  no  projection  of  the  seminal  fluid.  The  semen 
accumulated  in  the  eroded  pocket  of  the  verumontanum  and  escaped 
from  the  meatus  fully  ten  minutes  after  the  orgasm.  This  anatomic 
deformity,  very  unusual  by  the  way  (Plate  V,  Fig.  1),  explained  clearly 
and  surely  the  pain  at  the  moment  of  orgasm  as  well  as  the  sterility. 
Urethroscopic  therapy  consisted  in  destroying  the  anterior  wall  of  the 
pocket  of  the  verumontanum  with  the  galvanocautery  and  as  a  result 
the  ejaculatory  pains  disappeared  entirely. 

In  other  cases  the  s^miptoms  in  connection  with  emission  are  less 
marked,  but  they  exist,  nevertheless,  and  the  simple  dilatation  of  the 
ducts  is  sufficient  to  cause  their  disappearance.  I  recall  a  patient, 
forty- three  years  of  age,  in  whom  the  ducts  were  dilated  three  or  four 
times;  and  after  this  treatment,  he  informed  me  that  it  had  restored 
the  virility  of  his  youth  and  that  never  before  had  sexual  relations  been 
so  pleasant. 

In  still  other  instances,  the  ill-defined  pains  from  which  the  pa- 
tients suffer  during  the  sexual  act,  keep  them  from  indulging,  and  thus 
tending  to  inculcate  the  belief  that  they  are  really  impotent.  As  a  re- 
sult, when  these  pains  cease  after  treatment,  they  are  perfectly  happy 
to  note  the  return  of  their  virility. 

Finally,  I  have  observed  in  a  number  of  instances,  ^^^thout  being 
able  to  offer  any  explanation  for  the  phenomenon,  that  the  induration 
in  the  epididymis  which  followed  an  acute  inflammation  has  disap- 
peared in  many  cases  as  the  result  of  the  systematic  and  methodic 
dilatation  of  the  ejaculatory  ducts.    Doubtless  this  was  due  to  the  indi- 


ENDOURETHRAL    TREATMENT    OF    TROSTATIC    JTYPERTROniY  135 

rect  effect  piodiiccd  l)y  tlic  draiiiaiic,  tlius  pci'inittiii,^  llic  easy  evaeua- 
lioii  ol*  tlic  itircctiMl  |)i-()(liicls  ill  tlic  sciiiiiial  vesicles. 

As  a  result  of  this  study  we  may  conclude  tliat  catlietci'izatiou  of 
tlie  ducts  is  a  uiaueuvei-  wliicli  should  be  carried  out  as  a  routine  treat- 
iiH'iit;  riiitlicniioic,  when  pi-operly  performed  under  favorable  circum- 
stances, it  lias  never  i^roduced  the  slightest  inflammation  or  accident. 
AVe  may  safely  say  that  catheterization  of  the  ejaculatory  ducts  con- 
stitutes one  of  the  finest  achievements  of  modern  urethroscoi^y. 

ENDOURETHRAL  TREATMENT  OF  PROSTATIC 
HYPERTROPHY 

Freyer  has  demonstrated  conclusively  the  undoubted  value  of 
transvesical  prostatectomy  in  the  treatment  of  hypertrophy  of  the  pros- 
tate. There  can  be  no  doubt  that  this  operation,  in  experienced  hands, 
frees  the  patient  from  the  thralldom  of  the  catheter  and  from  the  dan- 
gers which  accompany  its  use.  But  it  is,  nevertheless,  true  that  while 
this  operation  is  decidedly  indicated  in  the  case  of  a  very  large  prostate, 
there  are  many  instances  in  which  the  distress  evidenced  by  the  pa- 
tient is  not  of  sufficient  intensity  to  justify  an  operation  of  such  ad- 
mitted gravity. 

It  is  admitted  that  the  operation  is  demanded  in  complete  reten- 
tion, in  the  presence  of  a  very  large  prostate,  or  when  the  urine  is  in- 
fected. On  the  other  hand,  however,  with  incomplete  retention  of  clear 
urine,  varying  in  quantity  between  fifty  and  two  hundred  cubic  centi- 
meters, but  accompanied  by  increased  frequency,  pain  at  the  beginning 
and  end  of  urination,  and  diminution  in  the  poAver  of  the  stream,  the  op- 
eration is  truly  out  of  all  proportion  to  the  symptoms  observed.  It  is 
in  this  type  of  case  that  the  endoscopic  treatment  should  be  undertaken. 

This  method  of  treatment  has  been  applied  by  all  observers  who 
have  taken  up  iDosterior  urethroscopy  systematically,  and  Cioldschmidt, 
one  of  the  pioneers,  obtained  appreciable  results.  Unfortunately,  as 
Harpster  has  pointed  out,'  Goldschmidt's  instrument  is  very  delicate, 
the  lamp  deteriorates  easily,  and  in  addition,  hemorrhage  is  frequently 
l)roduced  which  comj^letely  obscures  the  field  of  vision. 

The  use  of  endoscopy  in  prostatic  ]iy]>ertrophy  is  found  to  be  com- 
pletely justified  by  the  anatomic  condition  of  the  deformities  which  re- 
sult in  the  urethral  canal.  In  the  numerous  researches  which  I  have 
made  in  cases  of  prostatic  hypertrophy,  one  fact  has  seemed  to  me  to 
be  constant;  naincly,  tliat  in  every  case  with  retention  of  urine,  my 
urethrosc()]uc  tul)o,  instead  ol'  ])en(^trating  easily  and  directly  into  the 
prostatic  urethra  and  the  bladder,  was  always  stopped  at  the  neck  of 


136  CYSTOSCOPY   Al^B    URETHROSCOPY 

tlie  bladder  by  a  prostatic  bar.  This  bar  is  invariably  located  at  tlie 
same  place;  i.  e,,  at  the  j^rostatic  fossetto,  Avhich  is  situated  in  front  of 
the  vesical  neck  and  behind  the  posterior  aspect  of  the  verumontaimm ; 
in  prostatic  hypertrophy  this  space  natnrally  undergoes  a  decided 
anteroposterior  lengthening. 

Consequently,  the  introduction  of  a  straight  tube  into  the  posterior 
urethra  is  always  impeded  in  prostatic  hypertrophy  by  this  prostatic 
bar,  which  prevents  the  tube  from  entering  the  bladder.  It  is  then 
cjuite  natural  to  expect  that  therapeutic  efforts  should  tend  toward  the 
elimination  of  this  bar  so  as  to  prevent  the  accumulation  and  retention 
of  the  urine;  this  is  what  Bottini  sought  to  effect  by  blind  methods  with 
his  galvanic  incisor.  This  operation  has  been  completely  abandoned 
for  the  reason  that  it  was  done  completely  in  the  dark. 

The  endoscopic  method,  on  the  other  hand,  is  used  under  the  con- 
trol of  the  eye  and  can  be  readily  regulated  both  as  to  the  intensity  of 
the  action,  as  well  as  to  the  extent  of  surface  to  be  dealt  with.  The  nu- 
merous endoscopic  investigations  which  I  have  made,  have  given  me 
the  form  and  the  size  of  this  prostatic  bar.  Practically  always  it  may 
be  likened  to  a  roof  with  two  sloping  sides.  One  of  these  slopes  to- 
ward the  bladder;  in  general,  its  degree  of  declivity  is  rather  slight. 
The  other  slopes  toward  the  urethra  and  its  declivity  is  usually  more 
al3rupt,  almost  vertical  at  times.  Often,  the  top  of  the  roof,  which  is 
the  junction  of  the  two  sides,  constitutes  a  more  or  less  acute  angle,  but 
occasionally  it  is  flattened  in  the  form  of  a  plateau. 

The  treatment  to  be  applied  to  the  prostatic  bar  aims  at  its  com- 
plete destruction  both  from  the  urethral  and  vesical  directions.  In 
this  connection,  it  would  appear  at  first  thought  that  the  urethral  ap- 
proach is  the  easier  of  the  two,  but  such  is  not  at  all  the  case.  On  the 
contrary,  the  jDrostatic  bar  is  best  attacked  from  the  vesical  direction 
with  my  direct  vision  cystoscope,  and  it  is  only  at  the  end  of  the  treat- 
ment Avhen  it  is  advisable  to  complete  the  work  on  the  urethral  side, 
that  the  simple  urethroscopic  tube  can  be  employed  to  advantage. 

REFEREiSrCE 

iHarpster:     Prostatotomy  by  the  Method  of  Goldsehmidt,  Section  on  Genitourinary  Diseases, 
Am.  Med.  Assn.,  1913,  p.  280. 

Operative  Technic 

The  operative  technic  is  simple.  For  the  oi^erative  details,  the 
reader  is  referred  to  page  229.  The  cystoscoxoic  tube  passes  easily  into 
the  bladder  in  the  vast  majority  of  cases,  facilitated  by  the  elbowed 


i';.\i)()i"i:i;'i'i  I  i;ai,  'iin^AiAi  lox'i'  oi-   i'kos'iwi'ic    ii  n  i'i;i:'i'i;i)i'ir,'  \.u 

<)i)tiiral<)r.  ( )iicc  iiil  rodiiccd  into  llic  liladdcr  and  llic  urine  willidi-awii, 
llic  base  of  the  Madder  and  llie  two  prostalie  lolx's  are  iden1i(ie(|.  1'!ie 
normal  ^^rooxc  lielwcen  llie  lohes  is  folloWLMl,  llie  lube  hein*;'  witlidrawii 
,i;i'a<lually  in  llie  nieaniinie.  The  \-esi('al  slojjo  of  tli<!  ])i'oslali('  har  is 
now  ()l)sei-\-e(l,  and  llie  cauleri/alion  Weft'iiis  at  tills  point.  A  few  di'ops 
of  cocaine  solulioii  are  deposited  on  the  spot  \\1iicli  i<  to  he  ;dtack'e(l. 
'Then  havin.i;-  waited  a  J'ew  luiiiiites  lor  the  anestlielic  (d'fcet,  tlio  vesical 
asi)ect  of  the  prostate  is  l)uriied  willi  tlie  galvanoeaiitery  point. 

Tlie  operator  tliiis  digs  a  real  ditcli  in  tlie  prostate;  and  when  it 
is  done  skilirully,  it  is  very  curious  to  note  that  there  is  little  or  no 
lieinorrhage.  This  cauterization  produces  just  a  little  black,  dry  eschar 
froin  ^v]^ch  there  is  no  oozing  of  any  kind.  As  the  cystoscopic  tube  is 
slowly  Avithdrawn  with  the  cautery  in  action,  a  real  bed  of  fire  is  thus 
dug  on  the  upper  margin  of  the  prostate  until  the  tube  reaches 
the  urethra. 

This  i^rocedure  can  not  be  completed  at  one  sitting.  Very  deep 
cauterizations  of  the  prostatic  bar  do  not  give  satisfactory  results;  and 
the  best  results  are  attained  when  the  applications  of  the  galvano- 
cautery  are  made  at  fairly  long  intervals,  the  most  satisfactory  being 
al)out  once  in  eight  clays.  With  these  precautions  in  mind,  accidents 
will  never  occur. 

The  first  application  is  usually  the  most  difficult,  for  the  road  has 
not  yet  been  jorepared.  The  prostate  is  congested  and  bleeds  easily 
at  the  slightest  contact.  With  patience  and  the  observance  of  due  pre- 
cautions, really  interesting  results  may  be  expected. 

The  best  way  to  determine  that  the  operation  is  finished,  i.  e.,  that 
the  jDrostatic  bar  has  been  completely  destroyed,  and  that  there  is  no 
further  danger  of  a  relapse,  is  to  make  an  examination  with  an  ordinary 
straight  urethroscopic  tube.  If  this  tube  passes  without  difficulty  di- 
i-ectly  from  the  urethra  into  the  bladder,  it  indicates  that  the  prostatic 
bar  no  longer  exists  and  that  the  desired  result  has  been  attained. 

Results  of  the  Treatment 

The  i-esults  are  decidedly  conclusive.  Two  principal  facts  are  to 
he  noted  after  this  treatment.  On  the  one  hand,  the  complete  disap- 
])earance  of  the  bladder  residue  which  was  formerly  present,  and  on 
the  other  hand,  the  increased  force  of  tlie  uiinary  stream.  The  patient 
who  before  the  treatment  used  to  "urinate  ou  his  jjoots,"  to  nsi^  a 
hackneyed  ]ihrase,  now  has  a  strong  and  normal  stream. 

Among  tlie  cases  which  I  have  treated  in  this  way,  one  is  of  ])ar- 
ticular  interest.  The  patient,  aged  forty-seven,  com})lained  of  difficulty 
in  urination.    This  consisted  first,  in  the  fact  that  it  took  some  time  to 


138  CYSTOSCOPY    AND    URETHROSCOPY 

start  tlie  stream ;  next,  there  was  a  diminution  in  the  force  and  volume 
of  the  stream,  and  finally,  that  he  suffered  pain  at  the  beginning  and 
end  of  the  act.  Residual  urine  was  clear  and  amounted  to  only^O  c.c. 
Examination  of  the  bladder  with  the  urethroscopic  tube  was  pre- 
vented by  the  existence  of  a  large  and  well-defined  prostatic  bar.  Onl}^ 
a  tube  Avitli  elbowed  obturator  could  be  passed  into  the  bladder.  Treat- 
ment with  the  direct  vision  cystoscope  extended  over  a  period  of  about 
three  months.  At  the  end  of  that  time  as  the  result  of  many  applica- 
tions of  the  galvanocautery,  the  urethra  was  completely  freed  of  its 
prostatic  bar.  The  straight  urethroscopic  tube  easily  passed  from  the 
urethra  into  the  bladder.  Not  only  was  the  patient  relieved  of  his  pains 
at  the  beginning  and  end  of  urination,  but  in  addition  he  noted  with  joy 
that  his  stream  Avas  large  and  had  an  excellent  projection;  he  uri- 
nated without  any  delay  and  his  residuum  was  nil. 


CHAPTER  IV 
CYSTOSCOPY 

Cystoscopy  may  be  defined  as  the  examination  ol:'  the  vesical  iiiu- 
cosa  nnder  tlie  control  of  the  eye  witli  special  optical  instruments, 
1liroui!,li  tlio  natural  urinary  passage  and  without  surgical  incision  of 
llie  bladder.  Cystoscopy  has  become  one  of  the  most  essential  methods 
of  exploration  in  urologic  practice.  Its  indications  are  innumerable; 
its  field  of  action  is  very  great,  for  it  includes  all  affections  of  tlie 
prostate,  kidneys,  and  ureters. 

Without  cystoscopy  it  is  absolutely  imxDossible  at  the  present  time 
to  make  a  correct  diagnosis  in  disease  of  the  kidneys.  Likewise  we 
are  enabled  by  means  of  meatoscopy,  that  is  to  say,  the  inspection  of 
the  orifices  of  the  ureters,  as  well  as  through  catheterization  of  the 
ureters  and  the  collection  of  the  separate  kidney  urines,  to  determine 
to  a  mathematical  certainty  whether  one  or  both  kidneys  are  diseased. 
Cystoscopy,  therefore,  not  only  furnishes  the  correct  diagnosis  in  kid- 
ney affections,  but  what  is  still  more  important,  it  determines  quite 
clearly  the  condition  of  the  diseased  organ  and  the  indications  for 
nephrectomy,  when  necessary. 

Again,  the  introduction  of  a  catheter  into  the  kidney  pelvis,  en- 
lightens us  as  to  its  capacity  and  makes  it  possible  also  to  evacuate  its 
pathologic  contents.  Antiseptic  lavage  of  the  pelvis  can  thus  be  per- 
formed; this  method  of  therapy  will  usually  improve  and  at  times  com- 
pletely cure  certain  mild  cases  of  pyelonephritis. 

Still  further,  by  the  introduction  of  opaque  liquids  sucli  as  coUar- 
gol  into  the  interior  of  the  kidney  pelvis,  combined  with  the  roentgen 
ray,  w^e  are  enabled  to  obtain  a  clear  radiogram  of  the  pelvis  and  to 
deduce  important  diagnostic  and  therapeutic  conclusions. 

In  ureter  disease,  such  as  calculi,  tumors,  kinks,  etc.,  cystoscopy 
permits  the  introduction  of  a  catheter  into  the  ureter,  which  tells  us 
whether  the  latter  is  patent,  obstructed,  or  kinked.  I'he  information 
of  the  presence  of  a  foreign  body;  i.  e.,  calculus,  in  the  ureter,  tlius  ob- 
tained, will  result  in  eliciting  the  proper  indications  for  surgical  inter- 
vention. 

In  addition  to  the  data  derived  ^^■ilhill  the  ureter,  the  ureteral 
catheter  also  furnishes  other  and  highly  iiii])()i-ianl    inrorniation.     By 

139 


140  CYSTOSCOPY    AND    URETHROSCOPY 

means  of  a  metallic  stylet  within  the  ureteral  catheter  or  the  x-ray 
catheter  impregnated  so  as  to  intercept  the  roentgen  rays,  we  are  en- 
abled to  take  a  radiogram  of  the  pelvis,  as  well  as  the  direction  and 
shape  of  the  ureter. 

Finally,  one  of  the  most  interesting  and  useful  applications  of 
the  ureteral  catheter  from  the  therapeutic  standpoint  is  found  in  con- 
nection with  renal  colic.  I  have  often  had  the  opportunity  of  observing 
during  the  crisis  in  nephritic  colic,  that  a  ureteral  catheter  introduced 
between  the  calculus  and  the  ureteral  wall  on  being  rather  suddenly 
withdrawn  will  initiate  a  downward  movement  of  a  hitherto  stationary 
calculus  and  culminate  with  its  subsequent  exit  from  the  ureter  into 
the  bladder. 

Cystoscopy  is  distinctly  indicated  in  all  affections  of  the  bladder. 
It  is  only  by  the  aid  of  this  means  of  examination  that  the  exact  diag- 
nosis in  bladder  disturbances  can  be  made.  Thus,  tumors  of  the  blad- 
der, for  example,  are  easily  recognized,  and  it  can  not  be  denied  that 
the  precision  of  this  method  of  diagnosis  is  far  superior  to  the  older 
clinical  methods  of  palpation  which  always  left  the  diagnosis  vague 
and  uncertain.  Indeed,  it  is  not  too  much  to  say  that  an  experienced 
cystoscopist  can  often  distinguish  at  a  glance  between  a  benign  and  a 
malignant  growth,  thereby  affecting  the  prognosis  considerably. 

When  a  stone  is  suspected,  cystoscopy  can  be  relied  upon  to  give 
a  positive  diagnosis;  for,  although  the  presence  of  a  large  stone  can  be 
determined  by  the  aid  of  a  metallic  searcher  in  the  bladder,  it  is  a  fact 
that  small  stones  may  completely  escape  identification  by  this  method. 
Likewise  when  small  stones  are  encysted  between  trabecu]?e  or  in  diver- 
ticulae,  their  existence  can  be  discovered  only  through  the  aid  of  the 
cystoscopy  The  same  is  true  after  lithotrity,  when  it  is  necessary  to 
make  sure  that  all  the  fragments  have  been  thoroughly  evacuated  and 
that  there  are  no  more  in  the  bladder.  Cystoscopy  is  invaluable  for 
this  purpose. 

Foreign  bodies  in  the  bladder  can  not  really  be  diagnosed  except 
by  the  aid  of  the  cystoscope.  When  they  have  lain  for  a  long  period  in 
the  bladder,  they  are  usually  covered  over  with  a  layer  of  phosphatie 
salts  which  eventually  transforms  them  so  that  they  resemble  a  true 
stone.  Cystoscopy  makes  the  diagnosis  exact  by  revealing  their  cor- 
rect size  and  shape. 

In  all  cases  of  chronic  cystitis,  cystoscopy  is  indicated  for  the  pur- 
pose of  determining  the  bladder  condition  and  its  etiology.  In  tuber- 
culosis, for  example,  the  ulcerations  resembling  finger  scratch  marks 
are  so  typical  and  characteristic  of  this  disease,  that  the  real  cause  of 
the  cystitis  may  be  attrilmted  to  the  Koch  bacillus  on  the  strength  of 
these  findings. 


CYSTOSf'Ol'Y  141 

Cystoscopy  is  also  indicnic*!  in  disease  of  ilic  jtrcjstalc  In  ])!•()- 
static  liypertropliy  in  particular,  cystoscopy  makes  il  ])()ssihl("  1o  dis- 
tingiiisli  not  only  the  enlarged  lobes,  but  also  tlui  true  slia])e  of  llic 
organ  and  the  amount  of  j^rojection  of  the  lobes  into  the  bladder.  Tlic 
median  lol)e  and  its  various  conformations  can  likewise  be  cardHliN 
studicMl.  This  method  of  examination  is  useful  in  many  ways  and 
should  never  be  overlooked.  As  Marion^  has  well  put  it:  "Cystoscop}' 
enjoys  the  particular  facult}'  of  revealing  entirely  unsuspected  lesions 
at  times,  especially  calculi  and  tumors,  in  cases  in  which  llic  Cunclional 
disturbances  were  not  of  sufficient  gravity  to  attract  special  attention; 
in  this  manner  cystoscopy  offers  exact  information  upon  which  spe- 
cific therapy  may  be  based." 

In  prostatic  hypertrophy  the  normal  aspect  of  the  vesical  neck  is 
altered  to  a  varia])le  degree.  There  are  important  modifications  in  the 
reciprocal  relations  between  the  neck  of  the  bladder  and  the  ureters. 
Indeed,  under  the  influence  of  prostatic  enlargement  the  hypertroj^hied 
neck  is  drawn  upward  and  backward,  while  the  orifices  of  the  ureters 
remain  stationary.  Consequently  the  distance  from  the  vesical  neck  to 
the  fundus  is  increased  perceptibly.  Cystoscopy  also  reveals  the  ex- 
istence of  a  vesical  lesion  which  is  always  constant  in  i^rostatic  hyper- 
trophy; that  is,  the  presence  of  columns  of  trabecular  disseminated  over 
the  entire  surface  of  the  vesical  mucosa  and  especially  at  the  fundus. 

Finally,  cystoscopy  finds  one  of  its  most  frequent  applications  in 
the  numerous  urinary  disturbances,  b)^  enabling  us  to  interpret  the 
conditions  which  apply  to  the  kidneys,  bladder,  ureters,  or  the  prostate. 
We  can,  therefore,  readily  see  wdiat  a  great  field  cystoscopy  enjoys,  and 
the  numerous  conditions  in  Avhich  w^e  may  have  recourse  to  the  enlight- 
enment which  this  marvelous  method  of  examination  affords  for  the 
study  of  urinary  disturbances. 

However,  though  we  may  regard  cystoscopy  as  indispensable  in  al- 
most all  diseases  of  the  urinary  apparatus,  it  may  also  be  applied  in 
many  pathologic  conditions  quite  distinct  from  the  urinary  tract 
proper.  Thus  in  uterine  disease,  cystoscopic  indications  are  numerous. 
During  i3regnancy,  for  instance,  the  uterus  causes  the  bladder  to 
undergo  important  changes,  which  are  referred  to  in  a  later  chapter. 
In  cancer  of  the  uterus,  the  bladder  condition  will  very  often  give  ev- 
idence which  may  necessitate  complete  abdominal  hysterectomy  (see 
page  207). 

Previous  to  a  laj^arotomy  for  uterine  cancer  or  fibi'oid,  it  is  very 
important  to  insert  a  ureteral  catheter  into  each  ureter  so  that  it  will 
act  as  a  landmark  or  guide  during  the  operation.  This  will  ju'event 
injury  to  the  ureters  during  the  jDrocess  of  decortication  or  excision. 


142  CYSTOSCOPY   AISTD    URETHROSCOPY 

For  want  of  this  precaution,  ureters  have  been  injured  by  many  general 
surgeons  during  this  operation.  In  salpingitis,  c3'stoscopy  is  also  highly 
imiDortant,  and  I  have  been  able  to  observe  its  usefulness  in  thist^condi- 
tion  in  several  instances.  In  a  case  of  right  salpingoovaritis  a  patient 
in  the  service  of  Arrou  at  the  Hopital  cle  la  Pitie,  also  complained  of 
clearly  defined  pains  referred  to  the  right  kidney;  and  considering  the 
grave  accompanying  conditions,  such  as  increased  temperature  and 
poor  general  condition,  it  was  practically  impossible  to  determine  clin- 
ically whether  the  symptoms  observed  were  due  to  the  salpingitis  or  to 
a  pyonephrosis.  Cystoscopy  showed  that  the  right  ureteral  orifice  did 
not  functionate  properly  and  did  not  present  normal  clean-cut  urinary 
ejaculations.  In  addition  it  showed  that  this  ureter  was  impermeable 
to  a  No.  6  catheter,  thus  forcing  the  conclusion  that  this  canal  had  be- 
come constricted  somewhere.  The  ^Datient  was  i3ut  to  bed  with  ice  ap- 
plications to  the  abdomen.  This  treatment  was  followed  by  excellent 
results,  for  as  soon  as  the  inflammatory  condition  of  the  right  tube 
improved,  the  renal  troubles  disappeared  completely  and  the  pains  did 
not  return. 

In. other  eases  cystoscopy  enabled  us  to  locate  the  openings  of  pus 
collections  in  the  bladder  of  salpingitic  origin.  The  cystoscopic  ap- 
pearance of  these  vesical  perforations  has  been  drawn  from  nature  in 
Plate  X,  Fig.  2.    Reports  of  two  cases  follow. 

Case  1. — Supinirative  salpingitis  luith  localised  peritonitis  perforating  the  bladder.  A 
woman,  L.  E.,  aged  twenty-uiue,  was  sent  to  me  at  the  Broca  Hospital,  bv  Arrou,  on  December 
13,  1912,  with  purulent  urine.  Pus  had  suddenly  appeared  in  the  urine  in  January,  1911,  and 
from  that  date  had  never  disappeared.  Cystoscopic  examination  showed  a  healthy  bladder 
throughout ;  however,  a  large  fleshy  pimple  was  observed  on  the  base  of  the  bladder,  behind 
the  ureteral  oritices.  This  large  mass  obscured  an  orifice  through  which  pus  was  exuding ;  and 
which  admitted  a  catheter  No.  5  for  a  distance  of  about  one  centimeter.  The  ureteral  orifices 
appeared  to  be  normal. 

This  was  undoubtedly  an  abscess  which  had  ruptured  at  the  fundus  of  the  bladder. 
Operation  was  performed  by  Arrou  at  the  New  Pitie  Hospital  on  December  19,  1912.  In 
the  course  of  the  laparotomy  he  was  able  to  determine  that  there  was  a  perforation  of  the 
bladder  at  the  fundus  and  that  the  pus  was  emanating  from  an  enormous  salpingitis  situated 
in  the  lower  pelvis.     Both  tubes  and  the  uterus  were  removed. 

Case  2. — A  woman,  B.  B.  J.,  aged  twenty-nine,  was  referred  by  Arrou,  on  March  25, 
1911,  at  the  Broca  Hosj)ital,  because  she  had  very  purulent  urine.  Double  catheterization  of 
the  ureters  showed  that  the  two  kidneys  were  secreting  perfectly  clear  urine  and  that  the 
pus  could  not  possibly  come  from  that  source.  Vesical  cystoscopy,  on  the  other  hand,  showed 
that  while  the  entire  vesical  wall  was  generally  normal,  the  base  presented  an  edematous 
plaque  studded  with  tender  papules.  This  was  probably  the  site  of  a  vesical  perforation. 
Vaginal  examination  revealed  an  enormous  salx^iugitic  mass  which  was  attached  to  the  uterus. 

Perforation  of  the  Bladder  by  an  Abscess  of  the  Iliac  Fossa. — 

Cystoscopy  is  also  useful  in  cases  of  iliac  abscess,  as  the  following  case 
illustrates : 


CYSTOSCOPY 


143 


On  Ainil  1,  liHi'i.  M.  Ic  Mninc,  ;m  iiilcin  in  tlie  servico  of  R<k-1i:u<1  at  tho  Ilopital  St. 
Ldiiis,  r('(|U('st('i|  nil'  tn  cxiuniiii'  ;i  initicnt  whu  liml  ;i  fovoro  pyui-i;i,  }(i'f)1i:i1ily  of  kidnoy  origin. 
On  A[iril  S,  I  s;i\v  llir  |i;iticn1,  ;i  \v(ini;iii  iil^i'iI  1  li  i  it  y-cit^lil .  wlm  liml  ciitrriMl  tlic  hospital  on 
Ft'hruary  19,  li)()!t,  conipliiiiiiiig  of  paiii.s  in  tho  riyiit  iliac  fossa;  she  had  an  aftornooii  tcni- 
[iciatnie  of  r!S.S°  C  On  January  5  procodinj^j,  she  had  given  liirth  to  a  healthy  ehiM.  On 
eiitraiu'c  to  the  li(is|iital  slic  liad  clear  urine,  liut  a  few  days  later  her  urine  suddenly  heeanie 
(|uit('  ]iurul(Uit,  with  |inin  nl  tlie  end  (d'  urination.  SimuUnnrnusly  the  teiniieratiii-e  dropped 
to  :\7     C. 

In  spite  of  vesical  lavage  with  nitrate  of  silver,  the  pyuria  did  not  diniiiush.  In  addi- 
tion there  was  a  jiainful  swelling  in  the  right  gioin,  suggesting  the  possibility  of  a  purulent 
collection  at  the  right  Inoad  ligament  which  had  worked  itself  down  to  its  lower  margin 
liy   following  the   lound   ligament.     With  my   direct  vision  cystoscope  I  saw  that  the  bladder 


Fig.   87. — Star-shaped   cicatrix    resulting   from   a   perforation   of   the   bladder,    due    to   an   abscess    of   the   right 

iliac   fossa. 


was  normal  over  almost  its  entire  area.  Both  ureteral  oritices  were  normal  and  gave  no  evi- 
dence of  inflammation.  However,  at  the  junction  of  the  posterior  and  right  superior  walls  a 
little  fierydooking  mass  was  visible,  about  the  size  of  a  franc  piece,  and  made  up  of  fleshy 
looking  papules  which  bled  easilj'  on  contact.  These  papules  admitted  the  introduction  of  a 
ureteral  catheter  provided  with  a  metallic  stylet  to  the  extent  of  about  one  centimeter.  Just 
as  soon  as  the  stylet  was  withdrawn,  however,  a  mass  of  thick  pus,  like  custard  or  cream  inun- 
dated tho  entire  bladder;  this  showed  the  undoubted  existence  of  a  vesical  perforation,  which 
was  quite  contrary  to  the  original  diagnosis  of  renal  pyuria. 

Late  in  April,  1909,  the  skin  in  the  region  of  the  right  groin  became  red  and  inflamed, 
and  when  the  tumefaction  which  had  formed  there  was  incised,  a  profuse  pus  collection  was 
evacuated.     It  was  then  diained   for  about  fifteen  davs.     Immediatelv  after  the  incision  of 


144 


CYSTOSCOPY   AND    URETHROSCOPY 


this  abscess  the  urine  cleared  up  and  remained  quite  clear  when  the  wound  had  healed.  I 
examined  this  woman  a  second  time  on  May  19.  The  urine  was  still  clear,  and  the  bladder 
perfectly  normal  throughout ;  and  instead  of  the  perforation  which  was  visible  six  weeks 
previously,  there  was  simply  a  small  air-tight  scar   (Fig.  87).  *► 

In  diseases  of  the  intestinal  tract,  especially  cancer,  cystoscopy 
will  very  often  verify  the  presence  of  adhesions  or  ^perforations  which 
may  he  present  as  the  result  of  the  neoplastic  process.  In  appendicitis 
also,  cystoscopy  may  he  useful  in  avoiding  errors  in  diagnosis  Avhich 


Fig.   88. — View   of  a  vesical   perforation   of   an   adjacent  abscess. 


may  he  harmful.  It  is  well-recognized  that  it  is  often  difficult  to  deter- 
mine the  clinical  diagnosis  hetween  appendicitis,  ureteral  calculus, 
floating  kidne}^,  and  renal  colic.  By  studying  the  ureteral  orifices  we 
can  learn  whether  they  are  normal  or  otherwise;  if  they  are  not  normal 
in  appearance,  the  diagnosis  points  to  a  lesion  of  the  ureter  or  kidney, 
thus  eliminating  the  appendix  entirely. 

In  appendicitis  I  have  had  occasion  to  observe  appendicular  ab- 
scesses which  perforated  the  vesical  wall  and  opened  into  the  bladder. 
The  following  is  a  report  of  one  of  these  cases : 


CYSTOSCOPY  145 

Mnic  C.  B.,  aged  fifty-four  years,  piitorcd  llic  lIAjiilsil  S.iiiit  Louis  on  October  24,  1908, 
in  tlic  scrN'icc  of  IJocliai'il.  Some  ilnys  proviously,  slic  iidliccd  tli:il  licr  iirino  siuldonly  linr-amf 
I'xticincly  liiiliiil  and  muddy  and  sIic  complained  in  aildilinn,  ai'  sc\ri-c  imin  on  niination. 
Sli(\  was  i)ale  and  very  weak  while  lier  tcmpei'aturc  osfdllated  around  .''.9'^  C  On  examination 
il  was  noted  llial  llie  ri<^ld  kiilney  was  clearly  lowered  and  easily  jialpiiblc  bimanually,  and 
seemed  1(i  lie  sensitive  to  tlie  toiudi.  The  pain  provokeil  liy  1he  iiand  placed  on  the  anterior 
ahdonunal  wall  extended  to  tlie  riyiit  side  of  the  abdomen,  whi(di  preseided  mai-ked  museular 
resislaiicc  extending  to  the  right  iliac  fossa.  The  left  kidney  could  not  be  paljiated.  In  the 
jucsence  of  such  unmistakable  symptoms,  the  diagnosis  based  on  the  ]iurulent  mine,  the  pain 
and  the  hiniaiiual  examination  -of  the  right  kidney  seemed  unmislakahle ;  it  was  quite  ap- 
parent we  were  dealing  with  a  large  right  pyonephrosis. 

Before  operating  on  the  right  kidney,  howevei',  M.  Bodolec,  the  intern  on  duty,  asked 
lue  to  examine  the  patient  and  to  secure  the  separated  urines.  I  examined  her  on  Octoljer  27. 
The  vesical  urine  obtained  through  a  catheter  was  horribly  fetid  and  muddy  and  had  the 
color  and  consistency  of  pus.  The  vesical  capacity  was  normal,  and  measured  at  least  200 
e.c.  After  thorough  lavage  of  the  bladder,  I  applied  my  separator  without  any  difficulty 
and  after  a  few  moments,  and  quite  contrary  to  all  expectations,  the  right  side  of  the 
separator  produced  a  perfectly  clear  urine,  the  same  as  came  from  the  left  side.  During 
the  first  ten  minutes  the  right  tube  constantly  gave  forth  clear  urine,  but  at  the  end  of  that 
time,  a  heavy  discharge  of  thick,  creamy  pus  appeared  on  that  side.  A  little  while  later, 
clear  urine  again  appeared  on  this  side.  The  appearance  of  the  right  tube  was  quite  cliar- 
acteristic:  below,  clear  urine;  in  the  middle,  pure  pus;  above,  clear  urine.  On  the  left  side, 
the  urine  remained  clear  throughout  the  entire  examination. 

Analysis  of  the  separated  urines  was  made  by  the  staff  intern  in  pharmacy  with  the 
quantities  of  urine  for  both  kidneys  about  the  same: 


Bight  Kidney 

Left  Kidney 

Bladder 

Cryoseopic  Point 

—0.48 

—0.54 

—1.03 

Urea    (per  liter) 

4.80  gm. 

5.25  gm. 

6.75  gm, 

Chlorides   (per  liter) 

2.70    " 

2.80    " 

3.10    " 

1  le  result  of  this  analysis  showed  that  there  was  very  little  difference  between  the  two 
kidneys  and  that  the  enormous  flow  of  pus  in  the  right  tube  of  the  separator  did  not  seem 
consistent  with  the  relatively  satisfactory  kidney  examination.  We  were  then  dealing  with 
something  extrarenal  and  the  right  kidney  could  not  be  held  responsible  for  the  profuse  pyuria. 
I,  therefore,  suggested  that  a  cystoscopic  examination  be  made. 

The  following  day,  October  28,  I  applied  my  direct  vision  cystoscope.  I  saw  that  the 
bladder  generally  was  normal,  the  ureteral  'orifices  did  not  differ  from  one  another,  and  that 
the  base  of  the  bladder  was  but  slightly  inflamed.  But  behind  the  plane  of  the  ureteral 
orifices  to  the  right  of  the  medial  line,  a  gaping  circular  orifice  was  seen;  it  had  clean-cut 
edges  and  thinned  walls  and  was  about  eight  millimeters  in  diameter.  From  the  lumen  of 
this  opening,  purulent  masses  issued. 

These  cystoscopic  findings  fully  confirmed  the  tentative  diagnosis  and  explained  very 
clearly  the  data  previously  furnished  by  the  separator.  The  pyuria  was  certainly  due  to  a 
perforation  of  the  bladder  following  an  extraneous  abscess  which  had  ruptured  into  it.  The 
data  furnished  by  clinical  observation  exclusively  was  entirely  wrong;  the  cystoscope  proved 
',)eyond  doubt  that  the  suspected  right  kidney  was  unaffected  and  that  the  pyuria  came  from 
an  adjacert  abscess. 

This  diagnosis  was  later  confirmed  at  autopsy,  which  was  performed  by  M.  Bodolec. 
The  vesical  perforation  was  found  exactly  in  the  spot  which  had  been  indicated  by  cystoscopy. 
Hint  is  to  say,  about  five  centimeters  behind  the  right  ureteral  orifice.  The  edges  of  this 
lipeiiing  W'cre  perpendicular  and  did  not  seem  to  be  the  seat  of  inflammation:  the  bladder  wall 
at   that  point  was  of  normal  thickness. 

This  perforation  cominunieated  posteriorly  with  a  vast  pocket  filled  with  pus,  the  origin 
of  which  seemed  to  be  an  appendicular  abscess.     In  point  of  fact,  the  intestines  were  matted 


PLATE  VIII 

Figs.  1  and  2. — Cystic  and  purulent  Littre's  glands.  Looking  at  this  pic- 
ture one  can  readily  understand  the  therapeutic  importance  of  forcible 
dilatation,  which  breaks  wp  these  inflamed  glands. 

Fig.   ?,.—Morgagni's  lacunce  and  Littre's  glands  chronically  inflamed. 

Fig.  4. — Littre's  glands  chronically  inflamed. 

Fig.  5. — Pathologic  aspect  of  the  anterior  surface  of  the  verumontanum 
chronically  inflamed  for  years.  Exemplifying  the  ''mirror  of  the 
seminal  vesicles. ' ' 

Fig.  6. — Enormous  polypus  at  the   external  orifice   of   the   female  urethra. 


4 


Fig.  1. 


Fig.  2. 


Fig.  3. 


Fig.  4. 


Fig.  5. 


PLATE  VIII 


Fig.  6. 


AXATOMK'    COXSIDKRATIOXS  147 

tiJUcdirr  t(i\v;inl  tlic  riylit  siilc  nt'  (lie  |irl\ic  (•;i\ily  nml  ;i|i|h';i  ;  cl  lo  l,r  ailhricnl  (n  1  lie  ;ii|  j:ii-ciit 
pclvir  (iil;:iiis.  'I'liis  i  lit  est  i  ii:i  I  iiiiiss  imimminI  ;iiiiI  (iI  iscii  i  nl  llir  1jI:ii|iIit  .•iikI  iitr'rus  foniiiletcly 
:iihl  it  \v:is  iiiily  liy  st'|i!i  i  :it  i  ii^  tlirsc  aillicsidiis  tliiil  ;i  liiij^c  |Minilciit  |r.M-kct  situiitf'd  iihovc 
mill  to  tlic  riylit  nl'  (lie  lihiiMi'r  was  d  isc(i\crci|  ami  sii  Ii^r(|iicii1  ly  (ipriird.  The  iifcnis  am!  its 
ailni'xa   were  pci  iVrl  ly   mniiial. 

Oil  the  right  side,  the  ureter  was  slightly  compressed  hy  Iho  presence  of  the  pus  pocket 
and  was  slightly  dilated  below  llic  point  of  fonstriction.  This  explains  llic  somewhat  int'(M-ior 
fuiH-1  ioiial  ]i('r1'oi  niaiii'o  of  the  rij4lil  ]<idiicy  as  (-oiii|ia  i  cd  willi  tlic  Icl't.  On  examinativin,  liolli 
kidneys  were  found  iiractically  alike  in  all  i-esjiects ;  1  iiey  each  weighed  about  l^;")  grams  and 
were  rather  pale  and  soft.  Neither  of  them  showed  any  evidence  of  hydronephrosis.  The 
psoas,  the  lioiiy  liiim  of  the  ]iel\is  and   the  vei'lelii'al   rojuiiin  were  without  any  lesion  whatever. 

From  this  study,  tlie  following  conclusions  may  be  drawn:  1.  In 
tlic  diagnosis  of  pyuria,  it  is  absolutely  necessary  to  regard  tl'.e  clinical 
(lata  alone  as  insufficient,  inasnmcli  as  it  may  lead  to  serious  eiTor;  the 
! Methods  of  instrumental  exploration  and  examination  which  provide 
exact  information  should  also  be  employed.  2.  Cystoscopy  should  al- 
ways be  i:)erformed,  in  addition  to  the  separation  of  the  urines.  3.  In 
IDcrforming  endovesical  separation  of  the  urines,  it  is  very  important  to 
study  carefully  the  method  of  urinary  ejaculation  and  the  way  in  which 
the  j)us  and  urine  make  their  exit  from  the  respective  tubes  of  the 
sejDarator. 

REFERENCE 

iMavion:     La  Cystoseopie  dans  I'hypertrophie  de  la  prostate,  Jour,  d 'Urologie,  1912,  ii,  p.  ?,?,. 

ANATOMIC  CONSIDERATIONS 

In  order  to  become  familiar  with  the  bladder  with  the  aid  of 
cystoscopy,  whichever  instrument  may  be  emi^loyed,  it  is  essential  to 
establish  fixed  and  identical  landmarks.  With  this  purpose  in  mind, 
the  bladder  may  be  divided  into  four  principal  parts: 

The  first  consists  of  the  superior  wall,  vertex  or  dome,  which  ex- 
tends forward  from  the  bladder  neck  and  becomes  continuous  with  the 
second  portion  or  vesical  base,  after  having  described  its  curve  with  an 
anterosuperior  convexity.  This  is  the  largest  of  the  four  bladder  divi- 
sions. 

The  second  is  made  up  of  the  posteroinferior  wall  of  the  bladder, 
or  vesical  base  (bas-fond)  (fundus).  It  is  continued  upward  and 
l)ackward  with  the  vesical  dome.  It  is  separated  from  the  third  por- 
tion by  the  interureteral  ligament  or  muscle,  which  extends  between  the 
two  ureteral  orifices,  thus  separating  the  fundus  from  the  trigone.  This 
interureteral  ridge  is  one  of  the  most  iiii])()rtaiit  hiiidiiiarlxs  in  cystos- 
copy for  it  gives  the  opei-ator  his  l)earings,  so  that  he  can  tell  in  which 
region  of  the  bladder  his  cystoscope  happens  to  be,  to  what  depth  it  has 


148 


CYSTOSCOPY    AND    URETHROSCOPY 


penetrated,  and  Avhicli  segment  of  the  bladder  he  has  under  observation. 

At  times  the  interureteral  muscle  manifests  itself  under  the  form 
of  a  transverse  cord  which  elevates  the  wall  of  the  bladder.  J^  other 
times  it  is  hardly  noticeable  at  all,  and  forms  onlj^  a  transverse  coil  or 
fold  barely  visible.  It  may  be  described  as  follows :  A  median  portion, 
not  very  well  marked,  and  two  lateral  portions  Avhich  surround  the  or- 
ifices of  the  ureters  like  an  elliptical  pad  or  swelling,  and  which  deter- 
mines the  prominence  of  the  ureteral  orifices  above  the  vesical  floor, 
this  prominence  varying  in  different  individuals. 

According  to  the  investigations  of  Uteau^  the  total  length  of  the 
interureteral  ridge  averages  3.27  centimeters  in  the  male,  and  2.68  cen- 
timeters in  the  female.  The  distance  from  the  middle  of  the  ridge  to 
the  neck  of  the  bladder  averages  about  2.05  centimeters. 


Fig.   89. — The   floor   of   the   bladder,   showing  the   proximal   portion    of   the   ureter    (after   L,.    Testut). 

The  third  subdivision  of  the  bladder  consists  of  the  bladder  trigone 
or  the  triangle  of  Lieutaud.  The  three  angles  which  bound  it  are 
formed  by  the  internal  orifice  of  the  urethra  and  the  two  ureteral  or- 
ifices, one  on  either  side.  This  portion  of  the  bladder  is  separated  from 
the  fundus,  as  we  have  already  seen,  by  the  interureteral  ligament  or 
muscle.  It  is  continued  forward  to  meet  the  fourth  part,  or  vesical 
neck.  On  the  lateral  portions  of  the  trigone  and  immediately  adjoin- 
ing the  eminence  formed  by  the  termination  of  the  interureteral  ridge 
around  the  ureteral  orifice  are  found  the  so-called  ' '  paratrigonal 
]~;lanes."  At  this  point  the  vesical  mucosa  is  often  very  thin  and  trans- 
parent, so  that  the  course  of  the  ureters  may  sometimes  be  observed 
for  a  variable  distance. 

The  vesical  trigone  is  by  far  the  most  important  portion  of  the 


ANATOMIC    CONSIDEKATIONS  149 

bladder  from  tlie  cystoscopic  standpoint.  Indeed,  because  of  its  situa- 
tion immediately  adjacent  to  the  orifices  of  tlie  ureters,  the  trigone 
iiatui'ally  feeLs  the  first  effect  of  iiifhuiiiiiatious  involviiii;'  tlie  kidneys, 
wliich  empty  their  pathologic  products  at  this  point. 

We  have  already  seen  that  the  distance  between  the  two  ureteral 
orifices  is  equal  to  the  length  of  the  interureteral  ridge  itself.  Consid- 
ering the  distance  from  the  neck  of  the  bladder  to  one  of  the  ureteral 
orifices,  we  find  it  generally  averages  2.75  cm.  in  the  male  and  2.27  cm. 
in  the  female.  We  also  find  that  the  distance  from  the  ureteral  orifice 
to  the  median  line  averages  1.58  cm.  in  the  male  and  1.34  cm.  in  the 
female. 

The  fourth  portion  consists  of  the  neck  of  the  bladder  or  the  inter- 
nal vesical  sphincter.  The  neck  of  the  bladder  offers  entirely  different 
cystoscopic  appearances,  depending  on  whether  the  indirect  (pris- 
matic) or  direct  vision  instrument  is  used,  and  also  as  to  whether  the 
male  or  female  bladder  is  being  examined.  The  presence  of  the  pros- 
tate in  the  male  causes  many  diverse  and  variable  modifications  in  the 
appearance  of  the  bladder  neck.  This  portion  of  the  bladder  will  be 
considered  in  greater  detail  later  (see  j)ages  198  and  247). 

EEFERENCE 
lUteau:     Ann.  d.  nial.  d.  org.  genito-urin.,  1905,  p.  241. 

Normal  Color  of  the  Vesical  Mucosa. — The  normal  color  of  the 
bladder  mucosa  is  clear  yellow  or  rose  yellow,  but  this  is  subject  to 
many  modifications  and  variations  according  to  the  degree  of  fullness 
of  the  viscus;  indeed,  the  slightest  degree  of  inflammation  of  the  mu- 
cosa is  made  evident  by  the  appearance  of  a  more  or  less  reddish  tint. 
Normally,  the  mucosa  is  smooth,  glossy,  and  uniform  in  texture;  but 
when  it  is  inflamed,  it  becomes  dull,  velvety  and  mucoid  in  appearance. 
Cases  are  often  encountered  in  which  numerous  depressions  or  recesses 
appear,  which  give  a  more  or  less  trabeculated  appearance,  depending 
on  the  degree  of  inflammation  present;  the  bladder  in  this  condition  is 
then  described  as  columnar  or  trabeculated. 

It  is  of  the  utmost  importance  to  recognize  the  vessels  of  the  nui- 
cosa  which  are  made  visible  through  the  cystoscope.  In  the  normal 
bladder  the  arteries  are  seen  principally;  these  appear  in  the  form  of 
arterial  clusters  and  vascular  arborizations,  decidedly  attractive  in 
appearance  and  most  abundant  in  the  region  of  the  vesical  neck.  They 
are  often  arranged  in  the  form  of  a  star.  In  other  ])arts  of  the  bladder, 
their  appearance  is  practically  the  same  as  that  which  ()])litlialiiioscopy 
reveals  at  the  fundus  of  the  eye. 


150  CYSTOSCOPY   AND    UEETHROSCOPY 

The  veins  are  nsually  not  visible.  They  appear  like  dark  lines  of 
a  grayish  blue  color.  In  the  aged,  rather  thick,  superficial  veins  are 
often  seen,  of  dark  color  and  varicose  appearance. 

URETERAL  MEATOSCOPY 

Meatoscopy  is  the  study  of  the  ureteral  orifices  in  the  bladder  as 
seen  with  the  eye  through  the  cystoscope.  From  the  particular  aiDpear- 
ance  of  the  ureteral  orifices  we  may  obtain  information  which  may 
determine  whether  there  are  lesions  in  the  ureters  or  disturbances  in 
the  corresponding  kidney. 

The  points  to  be  examined  particularly  are  the  ureteral  orifice, 
the  character  of  the  ureteral  emission  or  ejaculation  of  urine  and  the 
situation  of  the  ureteral  orifice  in  relation  to  a  lesion  of  the  bladder,  a 
vesical  tumor,  for  example.  Meatoscopy  has  been  studied  particularly 
by  E.  Hurry  Fenwick,  who  has  devoted  a  great  part  of  his  work^  to 
this  subject,  and  also  by  Edgar  Garceau.^ 

Examination  of  the  Ureteral  Orifices 

In  order  to  identify  the  ureteral  orifices,  the  distance  from  the 
neck  of  the  bladder  to  the  ureteral  plane  should  be  borne  in  mind;  this 
has  already  been  referred  to  (see  page  148).  But  the  most  imx^ortant 
guide  in  finding  the  orifices  of  the  ureters  readily  is  the  interureteral 
muscle  or  ridge;  this  applies  quite  as  well  with  the  indirect  (pris- 
matic) cystoscope  as  with  the  direct  vision.  This  is  undoubtedly 'the 
best  guide  for  finding  the  ureteral  orifices. 

[In  teaching  cystoscopy  to  American  students,  the  editor  has 
found  a  most  valuable  guide  in  the  location  of  the  ureteral  orifices,  by 
comparing  the  vesical  field  of  vision  to  the  face  of  a  clock,  and  refer- 
ring to  the  segments  which  correspond  with  the  numbers  on  the  clock's 
face.  In  this  way,  it  is  found  that  the  ureteral  orifices  are  usually  lo- 
cated so  that  they  correspond  with  the  number  YIII  or  IX  for  the  right 
ureter,  and  III  or  IV  for  the  left  ureter.  Thus  it  is  easy  to  describe  the 
orifice  as  being  near  III  on  the  clock,  or  IX,  as  the  case  may  be.  This 
always  makes  it  easier  for  the  student,  and  even  for  the  experienced 
operator,  to  locate  the  orifices,  especially  when  they  are  very  small. — 
Editor.] 

Aspect  of  the  Ureteral  Orifices. — In  the  normal  state  the  orifices 
of  the  ureters  may  present  a  considerable  variety  of  form,  size,  and 
situation.  In  the  vast  majority  of  cases,  the  orifice  is  seen  as  a  semi- 
elliptic  projection  clearly  distinguished  from  the  vesical  mucosa;  it  is 


URETERAL   MEATOSCOPY 


151 


formed  liko  a  small  nipple,  cone,  or  eminence,  more  or  less  i-oundcd  and 
with  a  cleft  in  its  center  or  summit. 

This  cleft  is  usually  simply  a  line;  in  oth.er  instances,  it  is  in  the 
form  of  a  crescent  or  a  comma.  Occasionally  it  reseml)les  a  little 
l)()utoiniiere,  similar  to  a  pair  of  half-closed  eyelids.    Aoain  the  orifice 


Fig.  90. 


Fig.  91. 


Fig.  92. 


Fig.  93. 


Fig.  94. 


Fig.  95.  Fig.     96.  Fig.     97. 

Various  Aspects  of   the  Ureteral  Orifices   (Knorr^  and   Fe.n\vick=). 

Pig.  90. — Normal  ureteral   orifice  projecting  like   a   papilla    (Knorr). 

pig.  91. — Normal    ureteral    orifice    in    the    shape    of   an    oblique    cleft    (Knorr). 

Fig.  92. — Large,    open    ureteral    orifice    (Knorr). 

Fig.  93. — Ureteral    orifice    shaped    like    the    beak    of    a    clarionette    (Knorr). 

Fig.  94. — Ureteral    orifice    lengthened    into    a    sharj)    line    (Knorr). 

Fig.  95. — Narrow    ureteral    orifice    with    thickened    lips,    indicative    of    a    mild    pyelitis    (Fenwick). 

Fig.  96. — Arch-shaped    oxifice    indicative    of    a    ureteral    dilatation    (Fenwick). 

Fig.  97.— Golf-hole-shaped    ureteral    orifice,    indicating    a    destruction    of    the    kidney,    as    observed    in 
renal    calculus   and   tuberculosis    (Fenwick). 

iR.    Knorr:     Die    Cystoskopie    und   Urethroskopie   bcim    Weibe,    Berlin,    190b!.    Urban   and    Schwarzen- 

-Fenwick:     Ureteric   Meatoscopy   in   Obscure   Diseases    of   the   Kidney,    London,    1903,    Churchill. 


berg. 


152  CYSTOSCOPY   AXD    IJEETHEOSCOPY 

looks  like  a  scratch  mark,  sometliing  analogous  to  the  imi^ression  of  a 
horseshoe  on  hard  snow.  It  may  also  be  seen  in  the  form  of  a  little 
circular  orifice  or  a  small  oval  fossette;  and  finally,  it  may  res^nble  a 
more  or  less  gaping  chasm. 

The  orifice  is  sometimes  of  very  small  caliber  congenitally;  that 
is,  it  exists  at  the  time  of  birth  similarly  to  the  congenitally  small  ure- 
thral meatus.  This  anomaly  may  remain  unnoticed  for  a  long  period  of 
years;  it  is  frequently  the  cause  of  accidents  associated  with  ureteral 
and  pyelitic  dilatation,  which  at  first  appear  inexplicable.  The  path- 
ogeny of  these  accidents  is  soon  revealed  by  the  cystoscopic  discovery 
of  this  malformation. 

The  ureteral  orifice  may  also  be  the  seat  of  a  pathologic  atresia, 
owing  to  the  presence  of  a  vesical  tumor,  and  it  is  then  easy  to  under- 
stand the  importance  of  meatoscopy  in  such  cases.  Indeed,  in  such  a 
case,  a  stricture  of  the  ureteral  orifice  aoII  bring  on  a  retrograde  dila- 
tation of  the  ureter  and  of  the  pelvis  and  will  cause  renal  pains  in  the 
corresponding  kidney.  Through  meatoscopy,  we  are  enabled  to  deter- 
mine the  real  etiology  of  such  pains  and  are  thus  prevented  from 
wrongly  subjecting  the  kidney  to  treatment  when  the  bladder  is  really 
affected. 

Apart  from  the  matter  of  size,  there  are  a  number  of  other  peculiar- 
ities which  the  ureteral  orifices  may  present.  In  order  to  appreciate 
these  peculiarities  it  is  generally  necessary  to  compare  the  tAvo  orifices, 
one  with  the  other;  and  in  this  connection,  it  is  well  to  note  the  follow- 
ing facts  which  have  been  fully  described  by  Fenwick. 

A  ureteral  orifice  ma}^  be  congested  and  present  marked  vascular- 
ization. This  is  an  indication  of  hyperactivity  of  the  corresponding 
kidney  and  of  a  pyelorenal  inflammation  extending  toAvards  the  blad- 
der. Allien  the  orifice  is  turgid  and  elongated  and  the  lips  are  in- 
flamed and  congested,  dilatation  of  the  pelvis  and  of  the  corresponding- 
ureter  is  indicated.  AYhen  the  ureteral  meatus  is  ulcerated  and  pre- 
sents one  or  more  ulcerations  with  irregular  and  jagged  edges  like  a 
finger  scratch  around  its  orifice,  and  when  its  orifice  is  situated  in  the 
base  of  this  ulceration,  we  are  dealing  with  renal  tuberculosis  (Plate 
XVI,  Fig.  1). 

When  the  ureteral  orifice  takes  on  an  arched  appearance  resem- 
bling an  oval  arch,  we  must  think  of  the  first  phase  of  a  ureteral  dilata- 
tion which  has  extended  from  beloAA'  in  an  upward  direction.  A  ure- 
teral orifice  presenting  a  perfectly  circular  opening  indicates  a  dilated 
ureter.  Fenwick^  likens  this  picture  to  a  "golf  hole"  (Fig.  97).  In 
this  case  the  orifice  is  round  and  the  edges  small.  Its  dimensions  vary 
between  the  small  letter  "o"  and  a  capital  '^0,"  but  its  lips  are  never 


UKETERAL   MEATOSCOPY  153 

iiillaiiu'il.  Ilowcvci',  tlic  conroi-iiialioii  of  a  uiclci'al  oi-ilicc  is  not  always 
a  certain  indication  of  the  degree  of  dilatation  of  tlic  uiclci-,  for  tliis 
canal  may  liave  the  dimensions  of  a  chikl's  small  intestine  and  never- 
theless the  orifice  of  the  ureter  may  be  but  very  little  dilated.  When, 
liowever,  in  addition  to  this  appearance,  the  lips  of  the  orifice  are  red 
and  indamed,  it  indicates  that  the  corresponding  kidney  is  markedly 
pyelonephritic  and  that  tlie  renal  parenchyma  has  been  fundamentally 
changed. 

When  the  lips  of  a  dilated,  round,  ureteral  orifice  are  of  a  dirty 
white  color,  as  if  they  were  coated  with  wax,  while  the  surrounding  tis- 
sues are  red,  it  is  an  indication  that  a  periureteritis  is  present.  The 
ureter  then  appears  like  a  thick  red  cord.  This  appearance  is  met  with 
es23ecially  in  ureterorenal  tuberculosis.  A  ureteral  orifice  may  be  small, 
wrinkled,  distorted,  or  irregular.  It  is  then  an  evidence  of  a  pre- 
existent  erosive  ureteritis.  Occasionally  the  ureteral  orifice  is  sepa- 
rated in  two  by  a  little  bridge  of  tissue ;  this  is  generally  the  result  of 
the  cicatrization  of  a  preexistent  ureteral  ulceration. 

A  ureteral  orifice  with  a  papillomatous  appearance  indicates  the 
presence  of  a  chronic  irritating  discharge  from  the  ureter.  A  similar 
arrangement  may  be  seen  in  Plate  XII,  Fig,  3.  It  was  observed  in  a 
woman  with  acute  uric  acid  diathesis  who  passed  very  little  urine  and 
this  in  high  concentration.  The  ureteral  orifice  was  chronically  in- 
flamed, particularly  that  portion  which  was  traversed  by  the  irritating 
urine  which  had  left  its  mark  by  an  accompanying  inflammation. 

In  renal  lithiasis  the  slightly  conical  eversion  of  the  orifice  is  fre- 
quently found.  Prolapse  of  the  ureteral  orifice  may  be  more  or  less  ac- 
centuated. Sometimes  it  exists  only  at  the  very  moment  of  ureteral 
emission  and  resembles  the  rectal  prolapse  seen  in  defecation.  At  other 
times  it  may  be  more  accentuated,  j^resenting  the  appearance  of  a  real 
hernia  of  the  ureteral  mucosa,  even  simulating  at  times,  a  vesical  tu- 
mor. The  eversion  of  the  ureteral  mucosa  like  an  inverted  finger  of 
a  glove  diminishes  by  just  so  much  the  dimensions  of  the  orifice  and 
in  consec|uence  may  result  in  more  or  less  retention  of  urine  higher  up 
in  the  ureter. 

Retraction  of  the  ureteral  orifice  is  brought  about  by  the  fact  that 
tlie  ureteral  orifice  is  situated  at  the  base  of  a  deep  depression  of  the 
bladder,  instead  of  making  its  normal  projection  like  a  nipple  within 
the  bladder  (Pig.  98). 

In  these  cases  it  is  well  to  remember  that  the  ureter  which  is 
chronically  infiamed  and  shortened  thereby  causes  retraction  of  its  ori- 
fice.   It  is,  therefore,  reasonable  to  assume  that  this  arrangement  of  the 


154 


CYSTOSCOPY    AND    URETHROSCOPY 


orifice  indicates  the  existence  of  a  severe  pyonephrosis  of  the  corre- 
sponding kidne}^ 

Edema  of  the  ureteral  orifice  is  met  with  very  frequently*ln  the 
course  of  renal  or  ureteral  lithiasis  and  especially  coincident  with  or 
immediately  following  renal  crises.  This  accounts  for  the  fact  that 
catheterization  of  the  ureter  is  often  very  difficult  in  these  circum- 
stances. Indeed,  in  these  instances  the  orifice  is  sometimes  hardly  vis- 
ible, being  lost  in  a  mass  of  bullous  edema  resembling  small  whitish 
balloons  heaped  up  one  against  the  other  and  presenting  thin  reddish 


Fig.   98. — Retraction    of    the    ureteral    orifice,    the    result    of    an    inflammation    of    the    ureter. 


furrows  and  vascular  arborizations.  This  edema  of  the  orifice  is  often 
the  indication  of  renal  tuberculosis.  However,  it  must  not  be  con- 
fused with  the  cystic  dilatation  of  the  lower  extremity  of  the  ureter 
which  consists  of  a  single  swelling  of  rather  considerable  size  and  cov- 
ered over  with  a  few  small  vessels. 

Intravesical  dilatation  of  the  lower  extremity  of  the  ureter  has 
been  carefully  studied  by  Pasteau,*  Albarran,^  and  Bazy.^  This  dilata- 
tion can  be  determined  only  by  a  cystoscopic  examination  and  appears 
in  the  bladder  in  the  form  of  a  sessile  tumor  more  or  less  fully  pedun- 
culated and  implanted  in  the  ureteral  zone.    The  surface  of  this  cystic 


URETERAL   MEATOSCOPY 


155 


<lilatation  is  most  often  snioolli  and  coNci-cd  oxer  hy  a  noi-mal  mucosa, 
in  wliicli  (iiic  \-as<MiIai-  achorizalions  ina_\-  Ix-  seen    (  l^'i^',  99), 

Occasioiuilly  tlie  in-etei-al  orifice  is  situated  at  tiie  suniniit  of  the 
swelling,  but  at  other  times  it  is  almost  invisible,  and  tiie  diagnosis 
then  Ix'comes  more  difficult.  Howevei',  when  the  tumor  appears  near 
tlie  ureteral  zone,  it  is  always  well  to  lliink'  of  this  condition.  More- 
over, when  the  tumor  distends  itself  rhythmically  and  periodically  at 
the  moment  of  ureteral  emission,  the  diagnosis  is  quite  clear.  On  the 
other  hand,  the  diagnosis  is  not  a  difficult  one  when  there  is  a  single 


Fig.  99. — Prolapse   of  the  lower  extremity   of  the   right   ureter;   the   ureteral   orifice   cannot  be   seen    (Bazy). 

tumor,  smooth,  firm,  and  covered  with  a  healthy  mucosa,  in  the  ureteral 
zone.    It  can  hardly  be  anything  else. 

Bazy  has  explained  the  formation  of  cystic  dilatation,  which  he 
believes,  ought  to  be  designated  a  j^rolapse  of  the  ureter  in  the  blad- 
der. According  to  this  author,  this  affection  is  due  to  the  existence  of  a 
stricture  of  the  ureteral  meatus;  that  is  to  say,  from  the  pathogenic 
point  of  view,  it  seems  that  it  may  be  a  congenital  lesion  although  the 
unfortunate  symptoms  in  most  instances  do  not  become  numifest  until 
adult  life. 

If  the  ureter  above  the  contracted  ureteral  meatus  is  subjected  to 
violent  contractions,  proUqjse  ndglit  follow  in  the  same  manner  as  oc- 


156  CYSTOSCOPY    AND    URETHROSCOPY 

curs  in  prolapse  of  the  rectum  resulting  from  liemorrlioids.  The  ef- 
fort made  by  the  ureter  to  empty  its  contents  on  the  one  hand,  and  the 
difficulty  of  the  passage  of  its  contents  through  the  contracted  itreteral 
orifice  on  the  other,  constitute  the  predominating  factor  in  the  devel- 
opment of  these  cysts.  If  the  contents  are  liquid,  the  chances  of  pro- 
lapse are  small,  but  if  the  ureter  is  trying  to  expel  a  solid  body  like  a 
blood  clot  or  a  calculus,  the  effort  of  expulsion  is  greater  and  the 
chances  of  prolapse  will  be  correspondingly  increased. 

In  certain  cases  the  stone  descending  the  ureter  strikes  against 


Fig.  100. — Prolapse  of  the  ureter,  with  ureteral  calculus,  and  capped  by  a  secondary  vesical  calculus  (Bazy). 

the  crest  of  the  ureteric  orifice.  Little  by  little,  as  it  increases  in  vol- 
ume it  pushes  the  ureteral  walls  backward  and  around  it  according  to 
its  development,  and  thereby  determines  the  dimensions  of  the  ureter 
and  the  cavity  in  which  it  is  lodged.  As  Bazy  has  observed,  it  is  not 
the  cavity  Avhich  controls  the  size  of  the  calculus;  the  dilatation  above 
is  necessarily  secondary  to  the  existence  and  the  development  of  cal- 
culus. Albarran  has  cited  a  case  in  which  the  simple  pressure  of  the 
ureteral  sound  was  sufficient  to  reduce  the  prolapse  of  the  lower  ex- 
tremity of  the  ureter,  which  thus  returned  to  the  normal  completely. 
These  cystic  dilatations  of  the  lower  extremity  of  the  ureter  gen- 
erally yield  to  surgical  treatment,  which  should  always  be  transvesical. 


URETERAL   MEATOSCOPY 


157 


AVlion  tlie  tuinoi-  is  reached,  it  is  opened  freely,  and  tlie  calculi   re- 
moved, if  tliere  be  any. 

AiioiTialies  in  tlie  nioutli  of  the  ureters  are  not  rare;  the  two  illus- 


Fig.    101. — Aiii)ni:il\'    of    the   ureteral    orifices,    drawn    from    nature.      On    the    left,    are    two    ureteral    urilkes; 
on   the   right,   the   ureteral   orifice   is   normal. 

trations  which  are  here  presented  show  rather  interesting  anomalies 
which  I  have  myself  observed.  In  one  case  (Fig.  101),  there  were  three 
ureteral  orifices.    On  the  right  side,  the  orifice  was  in  its  iDroper  place 


Fig.   102. — Anomaly    of    the    ureteral    orifices,    drawn    from    nature.      Two    ureteral    orifices,    on    the    right 

side,   none  on  the  left. 


and  qnite  normal;  bnt  on  the  left,  there  were  two  ureteral  orifices,  one 
above  the  other,  in  the  direction  of  the  ureter.     On  the  left  side,  mid- 


158  CYSTOSCOPY    AND    URETHROSCOPY 

way  between  the  normal  and  tlie  abnormal  orifices,  there  was  a  short 
canal.  The  nrinary  stream  did  not  traverse  this  short  canal,  and  as  a 
consequence,  a  stagnation  of  urine  was  brought  about  which  resulted 
in  the  formation  of  pus  in  that  portion  of  the  canal,  which  was  half 
closed.  It  was  because  of  this  purulent  urine  that  the  patient  sought 
treatment. 

In  the  second  case  (Fig.  102)  there  AYere  two  ureters,  but  they 
were  both  situated  on  the  patient's  right  side.  On  the  left  side,  there 
was  no  orifice  whatever. 

The  ureteral  orifice  may  be  double ;  this  is  a  rare  anomaly,  but  it  is 
met.  Sometimes  there  are  two  ureters  for  a  single  kidney,  Avhich  open 
into  the  bladder  b}"  two  orifices.  Occasionally  while  one  of  the  two 
ureters  opens  normally,  the  other  is  closed  and  blind  and  constitutes 
a  little  cyst. 

The  orifice  may  be  lacking  altogether  on  one  side;  this  is  an  indica- 
tion that  there  exists  but  one  kidney.  Very  rarely  an  extravesical  ter- 
mination of  the  ureter  may  also  be  observed;  and  lastly,  the  appear- 
ance of  the  ureteral  orifice  may  sometimes  reveal  the  exact  diagnosis 
without  further  study.  This  occurs,  for  example,  when  a  small  stone 
has  become  impacted  in  the  ureter  or  when  a  clot  of  blood  or  a  parasite 
can  be  seen  at  the  ureteral  orifice. 

REPERElSrCES 

iFenwick:     Ureteral  Meatoscopy  in  Obscure  Diseases  of  the  Kidney,  London,  Churchill,  1903; 

also  A  Handbook  of  Clinical  Electric  Light  Cystoscopy,  London,  Churchill,  1904. 
2Garceau :      Vesical  Appearances   in  Eenal   Suppuration,  Boston   Med.  and   Surg.   Jour.,'  Jan. 

15,  1902. 
3Knorr:      Die  Cystokopie  und  Urethroskopie  beim  Weibe,  Berlin,  Urban  und  Schwarzenberg, 

1908. 
■*Pasteau:     Trans.  Vllle  session  Ass'n  francj..  d'Urologie,  1904,  p.  602. 
•'iAIbarran :     Ibid.,  p.  596. 
f'Bazy:     Eecueil  de  Memoires  d'Urologie,  July,  1911,  p.  125. 

Ureteral  Ejaculation 

Normall}^,  ureteral  emission  is  brought  about  in  the  following  man- 
ner: The  ureteral  meatus  begins  by  raising  itself  with  effort,  as  if  un- 
der the  influence  of  a  wave,  animated  by  the  contraction  of  the  mus- 
cular fibers  of  the  ureter.  Next,  the  orifice  opens  slightly,  giving  pas- 
sage to  a  jet  of  clear  liquid.  It  remains  open  an  instant  and  then 
contracts.  AVhen  this  emission  is  examined  carefully,  with  an  indirect 
cystoscope,  and  a  view  thus  obtained  through  the  water-filled  bladder, 
it  can  be  seen  that  the  urine  which  is  emitted  from  the  ureteral  orifice 
mixes  with  the  vesical  contents  like  a  jet  of  glycerin  would  mix  with 


I'ltK'i'Kit.M.  Aii':A'r()S('oi>v  159 

some  water,  Al'tcf  llic  ureteral  eiiiissi(»ii,  llie  orifice  of  the  ui'eter 
closes  and  i-emaiiis  in  (•oni|)lete  rest  imlil  1lie  next  ejaenlation  takes 
place. 

'J'lie  emission  is  oi'dinai'ily  icpeale*!  every  twenty  or  tiiirty  sec- 
onds, l)ut  tlie  intei'val  may  l)e  lon,ii,er.  Wlien  tlie  emission  is  studied 
with  the  direct  vision  cystoscope  held  in  profile,  an  actual  little  .jet  of 
water  is  seen  which  rises  lightly  ajjove  the  oritice  like  a  water  spout 
and  drops  down  upon  the  lateral  surface  of  the  oritice.  Tliis  arrange- 
ment has  been  drawn  after  nature  and  sliown  A\ell  in  Plate  X,  Fig.  6. 

The  ureteral  emission  may  l)e  more  or  less  vigorous  and  accentu- 
ated. It  is  generally  stronger  in  the  case  of  a  single  kidney,  as  seen, 
for  example,  after  nephrectomy.  It  is  also  more  highly  accentuated 
when  the  orifice  is  narrower.  Indeed,  when  an  examination  is  made  in 
the  air-filled  hladder,  with  my  direct  vision  cystoscope,  a  very  fine 
whistling  sound  may  he  perceived  at  the  moment  of  ureteral  emission. 
I  have  been  able  to  make  this  observation  very  clearly  in  a  case  where 
the  lumen  of  the  ureteral  meatus  Avas  found  considerably  constricted 
as  the  result  of  a  bloody  ulceration  of  the  right  ureteral  orifice.  At  the 
moment  of  emission,  a  kind  of  whining  sound  could  be  distinctly  heard. 

On  the  other  hand,  the  ureteral  emission  may  be  absent.  This  in- 
dicates either  that  the  corresponding  kidney  is  not  functionating  or  that 
the  ureter  has  become  obliterated.  This  phenomenon  is  observed  dur- 
ing chloroform  anesthesia,  and  it  may  also  be  met  with  in  especially 
sensitive  persons  when  a  nervous  spasm  is  produced. 

In  order  to  appreciate  better  the  subject  of  ureteral  emission  in 
all  its  details,  certain  methods  have  been  adopted;  among  these  may  be 
mentioned  the  subcutaneous  injection  of  a  sterile  solution  of  methylene 
blue  or  better  still,  of  indigo  carmine.  In  this  manner  the  ejaculation 
of  the  ureters  can  be  ol)served  with  far  greater  precision.  Certain 
authors  employ  indigo  carmine  injected  a  quarter  of  an  hour  before 
every  cystoscopic  examination.  In  this  way,  correct  information  con- 
cerning each  ureter  can  be  obtained  immediately;  and  when  it  is  known 
which  kidney  is  affected  and  to  be  catheterized,  innnediate  and  exact 
data  can  thus  be  secured.  This  method,  recommended  by  Voelcker  and 
Joseph,  gives  excellent  results.  It  is  well  to  remember,  however,  that 
it  consists  essentially  in  making  an  intramuscular  injection  of  4  c.c.  of 
a  sterile  4  per  cent  solution  of  indigo  carmine.  In  fifteen  minutes  the 
colored  ureteral  emissions  can  be  seen  with  the  cystoscope.  "When  the 
kidneys  are  normal  the  emission  resembles  a  puff  of  blue  cigarette 
smoke.  [When  the  indigo  carmine  is  injected  intravenously,  the  col- 
ored ejaculation  is  observed  much  more  quickly. — Editor.] 

Normally,  after  the  injection  of  indigo  carmine,  when  thi^  kidney 


PLATE  IX 

Fig.  1. — Papillomatous  tumor  of  the  bladder  situated  near  the  left  ureteral 
orifice  (before  treatment). 

Fig.  2. — Apioearance  of  the  same  tumor  as  above,  eight  days  after  galvano- 
cauterizatiou.  All  the  villas  of  the  tumor  have  disappeared ;  nothing 
remains  but  a  half  burned  stump,  which  readily  disapj)eared  under  a 
second  cauterization.  When  examined  a  year  later,  the  patient  showed 
no  trace  of  recurrence. 


Fig.  1. 


l-iR.  2. 

PLATE  IX 


URETERAL   MEATOSCOPY 


161 


is  ill  .i;()()(l  work i Hi;'  order,  llic  iirclcinl  orifice  is  easily  jukI  dearly  rec- 
o,i;'iii/('(l.  Iii(I('(mI,  ilic  jcl  of  si  roii^ly  coloi-cd  iiriiic  ciiiaiialing  from 
llic  urclcra!  orilicc  may  he  iilili/cd  as  a  iiscrul  ^uide  in  localiii£!,"  tlio 
oriliccs.  Tliis  is  os^x-cially  valiialtlc  for  Ix'^iiiiicrs  in  cystosco])y.  It 
sliould  always  he  icinciiilx'riMl  llinl  wlicii  a  kidney  does  nol  riinctionate 
l»i<)perly  or  is  entirely  lacking,  oi'  the  ureter  lias  become  obliterated, 
the  emission  of  bine  urine  does  not,  of  course,  take  place.  In  these  cir- 
(Ministances  it  would  be  inipossi))le  to  establish  the  diagnosis  by  the  aid 
of  iliis  iiiciliod  alone. 

The  ureteral  emission  may  also  contain  blood.     In  order  to  under- 


Fig.   103. — Ejaculation    of   thick   pus,    like    a    whirlpool,    from    a    ureteral    orifice    (Nitze). 


stand  with  what  precision  and  clearness  the  diagnosis  of  renal  hema- 
t iii-ia  may  be  made,  it  is  necessary  to  ol^serve  a  bloody  ejaculation  from 
a  ureteral  orifice  in  the  midst  of  a  clear  bladder  lluid,  scattering  itself 
like  the  smoke  of  a  cigarette  in  the  air.  A\nien  the  reiuil  hematuria  is 
marked,  the  condition  may  be  compared  with  a  factory  chinmey  emit- 
ting smoke  interiuittently.  Occasionally  in  addition  to  fresh  blood, 
elongated  worm-shaped  blood  clots  luay  be  seen  emerging  from  the 
ureters.  In  these  cases  we  should  think  of  the  i)ossible  existence  of  a 
renal  neoplasm. 

The  ureteral  emission  may  also  contain  pus;  and  it  is  always  in- 
teresting  whenever  x>(>^!^ibh'    to    note   the   manner    in    which   the   pus 


162  CYSTOSCOPY    AXD    rRETHROSCOPY 

emerges  from  tlie  ureteral  orifice.  When,  instead  of  liaving  a  real 
pnrnlent  emission  like  a  whirlpool  (Fig.  103)  the  pus  dribbles  out  at 
long  intervals  like  a  drop  of  vaseline  or  as  if  coming  out  of  a  ^ollapsi- 
)3le  j)aint  tube  (Fig.  101),  it  may  he  concluded  that  the  corresponding- 
kidney  is  functionating  very  badly. 


Fig.    104. — Ejaculation   of   pus  from   a   ureteral   orifice   as   from   a  tube   of  paint    (Nitze). 

Location  of  the  Ureteral  Orifices 

The  location  of  the  ureteral  orifices  often  has  to  be  noted  care- 
fulh^  when  surgical  intervention  is  rec{uired  in  the  bladder.  "When, 
for  example,  there  is  a  bladder  tumor  which  is  near  the  ureter,  it  is  well 
to  know  the  exact  relations  that  this  tumor  bears  with  the  ureteral 
orifice  before  undertaking  surgical  measures. 

ERRORS  IN  CYSTOSCOPY 

Though  cystoscopy  is  a  marvelous  method  of  examination  which 
it  is  impossible  and  even  rash  to  ignore,  it  is,  nevertheless,  true  as  we 
Jiave  already  stated,  that  the  essential  condition  making  for  its  use- 
fulness is  the  projDer  interpretation  of  the  pictures  which  it  furnishes. 
The  interpretation  is  of  prime  importance  and  this  can  not  be  accpiired 
except  by  a  large  exjDerience  and  considerable  practice.     There  is  no 


(loill 

)1   tli.-il   cri'ors  may  he  made 

all  t 

lie  dinicilllics  ol'  1  his   iiicHkx 

Willi 

('ys1()S('<)|)y. 

Ki;i:(»i;s   ly  cvstoscopv  K!.'' 

hy   lH'i;iiiii('rs  wlio   Ii.mnc   iioI    onci'coihc 
cNcii  llioiiuli  llicy  <'iij()_\'  a  I'amiliai'il  \' 

( )ii('  of  llic  errors  thai  iiia_\'  he  iiia(h'  is  lo  iiiisla!-;('  an  cxI  I'ax'csical 
liiiiior  which  ch'N'atcs  Ihc  x'csical  mucosa  For  a  liimor  of  ihc 
hhuhlci'  pfopci'.  '^Plic  most  siiiiph'  case,  as  well  as  Ihc  most  rrc(jiicii1,  is 
Ihal  whicli  is  observed  duriiijj,'  ])re^'iiaii('y,  when  the  hladtU'i-  is  i-aised 
hy  tlie  ,i;-rnvid  uterus.  In  tlie  same  way  the  l)ullous  edema  wliich  is 
ol'teii  met  with  in  tlie  rundus  of  the  reniale  hhuhlei'  is  soiiictiiiies  diK' 
solely  to  the  existence  of  a  uterine  cancer. 

A  second  error  wlncli  uuiy  be  made  is  tliat  of  niistakiuL;-  a  clironic 
cystitis  for  a  vesical  tumor.  Sometimes  the  cystitis  takes  on  sucli  ]jro- 
])ortions  tlud  it  com})letely  deforms  tlie  vesical  mucosa.  The  lattei-  oc- 
casionally i)resents  real  vegetations  wddch  simulate  a  real  tumoi-  of 
the  bladder.  The  imj^ortant  point  in  the  diagnosis  is  that  the  lesions 
are  nnu-h  more  limited  and  circumscribed  in  the  case  of  vesica!  tu- 
mors, while,  on  the  contrary,  they  are  in  most  instances  diffuse  and 
multiple  in  cystitis.  Nevertheless,  in  certain  cases  one  may  be  in  doubt 
as  to  the  correct  diagnosis.  I  have  found  myself  in  similar  circum- 
stances, and  the  only  method  that  has  enabled  me  to  establish  a  diag- 
nosis was  through  biopsy.  The  reader  is  referred  to  the  chapter  on 
Vesical  Biopsy  for  fiu'ther  details. 

The  differential  diagnosis  between  a  vesical  tumor  aiul  a  blood 
clot  is  sometimes  very  embarrassing.  The  best  procedure  consists  in 
trying  to  move  the  mass  by  means  of  the  cystoscope  itself.  The  clot 
is  mobile,  it  may  possibly  l)e  broken  up  and  does  not  bleed.  The  tumor 
on  the  other  hand,  does  not  j^ossess  these  characteristics,  hut  it  has 
this  special  feature;  namely,  that  it  bleeds  easily  on  the  slightest  con- 
tact. 

Cystoscopic  differential  diagnosis  between  a  benign  tumor  (iiajul- 
loma)  and  a  nu"ilignant  tumor  (cancer)  is  often  very  delicate,  and  as  in 
the  preceding  instance,  can  not  be  decided  at  times  except  through  bi- 
opsy; however,  it  is  possible  by  a  simple  cystoscopic  examination  in 
the  average  case  to  establish  (h^finitely  betAveen  a  benign  and  a  uialig- 
naid  tumor. 

Papillonui  is  more  fre(|ueid  than  cancer  and  ai)]tears  usually  in  tlie 
form  of  a  fringed  tunu)r,  lloating,  rose-colored  and  of  a  velvety  ras])- 
ben-ydike  appearance.  It  is  especiallv  characterized  by  tln^  lightness 
of  its  outline.  Vesical  papillomata  haxc  long,  tine,  slendei',  and  thin 
])i-olongations  which  extend  I'ai-  fiom  the  sui-facc  of  ini])lanta1i()U. 

Cancer,  to  the  conti-ary,  is  most  often  largei-  in  size,  with  a  more 
extensive  imjilantation.    Its  ap])earance  is  rough;  its  base  usually  seems 


164  CYSTOSCOPY    AND    URETHROSCOPY 

much  more  fixed  and  more  solid.  Finally,  in  the  vast  majority  of  cases, 
the  cancerous  tumor  presents  eschars  of  blackish  or  grayish  color.  This 
opaque  and  dark  coloring  is  not  met  with  usually  in  benign  tumors. 

Calculus  and  tumor  do  not  often  present  great  difficulties  in  their 
differential  diagnosis,  except,  however,  in  those  cases  in  which  the  tu- 
mor is  necrotic  and  encrusted  with  phosphates.  Weitz  reports  a  case 
of  tumor  encrusted  with  phosphates  in  which  the  error  in  diagnosis  was 
possible  even  with  the  naked  eye.  Like  a  case  reported  by  Dittel,  this 
proved  to  be  a  tumor,  which  was  removed  by  excision. 

In  the  average  case,  a  calculus  is  easily  recognized  by  its  mobil- 
ity when  touched  with  the  cystoscope;  a  calculus  never  pulsates  or 
beats  like  some  tumors  in  the  bladder;  and  lastly,  when  a  calculus  is 
touched  with  the  cystoscope  or  a  metallic  searcher  a  typical  resonance 
is  heard  as  a  result  of  the  contact. 

The  diagnosis  between  a  calculus  and  an  accumulation  of  pus  does 
not  present  any  difficulty.  However,  I  have  had  occasion  to  observe  a 
pertinent  case.  The  patient  was  suffering  from  retention  of  urine  of 
medullary  origin  and  was  obliged  to  catheterize  himself.  Cystoscopy 
showed  a  large  white  mass  in  the  fundus  of  the  bladder  which  gave  the 
impression  of  being  a  calculus,  at  first  sight ;  but  on  touching  it  with  the 
cystoscope,  there  was  no  sensation  of  contact  with  a  hard  substance 
and  the  whitish  mass  was  easily  broken  up.  Finally,  a  copious  irriga- 
tion of  the  bladder  brought  forth  large  purulent  masses,  thus  definitely 
determining  the  absence  of  a  calculus. 

Another  error  is  that  which  mistakes  a  diverticulum  of  the  bladder 
produced  by  the  crossing  of  two  vesical  trabeculse  for  a  ureteral 
orifice.  In  this  case  the  ureteral  catheter  makes  the  diagnosis  by 
striking  the  vesical  mucosa  at  the  base  of  the  diverticulum.  HoAvever, 
when  the  ureteral  meatus  is  very  small  and  narrow  (atresia),  it  is 
often  quite  difficult  to  say  whether  we  are  dealing  with  a  strictured 
ureteral  meatus  or  with  a  shallow  diverticulum. 

The  diagnosis  between  an  orifice  of  the  ureter  and  a  deep  ulcer- 
ation due  to  cystitis  is  often  a  delicate  one.  In  cystitis,  fissures  or 
rhagades  of  the  vesical  mucosa  are  sometimes  produced  and  between 
the  lips  of  these  fissures  are  seen  more  or  less  bloody  orifices  which 
might  be  mistaken  for  an  inflamed  ureteral  orifice. 

An  error  in  diagnosis  may  result  in  the  differentiation  between  a 
ureterocele  or  a  cyst  of  the  lower  end  of  the  ureter  and  a  tumor  of  the 
bladder.  An  instance  of  this  kind  which  has  been  observed  is  reported 
further  on  (see  page  235).  The  same  may  be  said  as  to  the  differential 
diagnosis  between  a  varix  of  the  bladder  neck  and  a  vegetating  tumor 
at  the  neck.    The  point  to  remember  is  that  bladder  tumors  at  the  neck 


dan(;ki;s  oi'  cystoscopy  165 

apjx'ar  most  oricii  in  tlic  U)V\\\  ol'  a  ,l!,I()\"('  (iii,L;'<'i',  i-atlicr  loni;-  and  thick, 
wlicrcnis  llic  vai-ic('S  arc  usually  attacliccl  to  tlic  l)la(l<l<'i-  nuicosa  and 
arc  immobile. 

Tlic  diagnosis  hotwoon  a  bladdoi-  tumor  and  an  onlaT-,£j:od  median 
]()l)c  of  tlic  ])rostatc  is  sometimes  i-atlicr  diffieult,  espeeially  as  these 
prostatic  lobes  are  frequently  pcdicuhiliMl,  thus  makiu.i;-  the  diagnosis 
(|iiite  complex. 

Bearino-  in  mind  all  the  difficulties  in  diagnosis  which  have  just 
hccii  enumerated,  it  is  essential  to  take  every  possible  precaution 
against  error;  among  these,  the  most  important  is  to  be  familial-  willi 
all  methods  of  examination  and  not  to  limit  oneself  to  a  single  instru- 
ment or  to  a  single  method.  We  shall  see  in  the  following  chapter  that 
both  indirect  (prismatic)  and  direct  vision  cystoscopy  should  be  of 
nmtual  assistance,  and  when  one  is  found  wanting,  Ave  must  turn  to  the 
other.  A  combination  of  both  of  these  methods  assures  a  mathemati- 
cally exact  and  absolutely  perfect  diagnosis. 

DANGERS  OF  CYSTOSCOPY 

A^Hien  cystoscopy  is  practiced  according  to  the  rules  which  are  de- 
scribed further  on  (pages  182  and  229)  it  is  absolutely  without  any 
danger,  and  when  carried  out  under  favorable  conditions,  it  is  as  easy 
as  simple  catheterization  of  the  bladder.  Nevertheless  all  the  precau- 
tions that  have  been  indicated  should  be  taken,  even  to  the  minutest 
degree.  The  first  of  these  precautions  and  the  most  important,  in  point 
of  fact,  is  a  most  thorough  asepsis.  If  this  is  neglected,  complications 
ma}^  result,  among  which  are  the  following : 

1.  Infection. — The  cystoscope  may  become  the  source  of  a  vesical 
infection  exactly  as  any  sound  that  is  not  aseptic  when  introduced. 
This  infection  makes  itself  apparent  by  the  usual  sAuuptomatic  triad, 
Avhich  is  observed  in  cystitis, — pyuria,  pollakiuria,  and  pain  after 
urination. 

2.  Bums  of  the  Vesical  Mucosa. — Formerly  when  warm  lamps 
were  used,  it  frequently  happened  that  little  burns  were  produced  when 
the  lamps  remained  long  enough  in  contact  Avith  a  given  point  of  the 
vesical  mucosa;  these  burns  appeared  in  the  form  of  round  spots  re- 
sembling a  more  or  less  pronounced  scar.  I  had  the  opportunity  of 
observing  similar  burns  some  years  ago,  Avhich  had  resulted  from  a 
cystoscopic  examination  which  had  been  made  some  days  previously 
by  a  colleague,  with  a  lamp  that  was  too  hot.  But  today  Avhen  the 
so-called  cold  lamps  are  employed  universally,  tliesc^  accidents  can  not 
occur. 


166 


CYSTOSCOPY    AND    URETHROSCOPY 


3.  Constitutional  Symptoms. — In  performing  cystoscopy  in  a  case 
of  severe  cystitis,  it  is  quite  certain  that  complications  may  he  induced, 
such  as  a  rise  in  temperature  and  a  severe  constitutional  I'^action. 
Care  should  he  taken  to  prevent  the  development  of  these  complications. 

4.  Electrical  Disturbances. — These  constitute  a  rather  disagree- 
able complication  Avhich  I  have  observed  twice,  and  which  I  could  not 
at  first  explain.  It  sometimes  happens  that  the  cystoscope  having  been 
introduced  properly,  and  the  conducting  wire  or  cable  applied,  the 
patient  suffers  a  very  painful  electric  shock  as  soon  as  the  current  is 
turned  on,  thus  rendering  the  examination  impossible.  After  many 
investigations,   every  possible   fault   of  the   instrument   having  been 


105. — Bladder    phantom. 


eliminated,  I  have  been  able  to  note  that  this  happened  only  in  cases 
in  which  the  patient 's  prepuce  Avas  so  long  that  it  came  in  contact  with 
the  arms  of  the  electric  conducting  rod,  and  that  in  these  circumstances 
a  short  circuit  was  produced, 

[In  the  editor's  experience,  this  phenomenon  has  occurred  even 
in  patients  who  had  no  foreskins  that  might  come  in  contact  with  the 
connecting  wire.  It  has  been  observed  that  a  moist  cement  or  wooden 
tioor  acts  as  conductor  of  the  current,  and  if  the  patient  places  his 
hands  on  the  sides  of  the  iron  table,  he  thus  completes  the  circuit  and 
produces  the  shock.  This  can  be  avoided  by  placing  a  thick  rubber  mat- 
ting or  sheeting  under  the  legs  of  the  table,  thus  insulating  it;  the 
operator's  stool  should  also  be  similarlv  insulated.     It  goes  Avithout 


DAXCIOIIS    OK    ('VST()S('()|'\-  1  ()7 

s.-iyiiii;'  llial  llic  |)ali<'iil  shall  likewise  lie  dii  a  nil)l)i'r  sheet  spread  over 
I  he  table. —  i^DITOIt.  I 

The  daiigcis  that  iiia\  Tolhiw  cat heteri/atioii  of  the  iirctors,  sucli 
as  iiir(>('tioii  and  perl'oi'at  ieii,  are  diseiis^^ed   lurther  en   (sec  pa.n'c  2f)';). 

Vesical  Phantoms.-  In  order  lo  learn  c\>-1oscopy,  hc.uiiiiici-s  will 
often  lind  it  to  their  adwanta^c  lo  use  phanloins  which  nix'c  a  picture 
similar  to  that  of  the  iiitorior  ol'  the  bladder.  These  phantoms  are 
iisuall>'  made  of  laihher,  and  their  iiiterioi-  is  paintetl  to  represent  the 
base  of  the  bladder  with  tlie  uretei'al  orifices  and  the  intern  rderal  li.i^'a- 
nieiit.  Numerous  moch'ls  may  be  had,  the  most  practical  beinii,-  those 
that  a])proaeli  i-eality  as  nearly  as  possible,  '^j'liese  are  jilled  with  water 
and  provi(h'd  witli  sy])lions  tliat  end  at  tlie  ima,uiuai->'  ureteral  oi-ifices. 
The  hitter  are  snrmonnted  with  two  1)otth'S  wliicli  re])i'eseut  the  ni-eters 
and  kidneys.  The  most  commonly  nsed  phantoms  are  tlie  moch'ls  made- 
by  Janet,  Frank,  Eitze,  Viertel,  and  AVossidlo. 

An  economic  way  to  secnre  a  phantom  is  to  make  one:  Take  a 
connnon  rnh])er  halloon  or  football  of  small  size,  the  ordinai-y  cl:ild's 
toy.  Make  a  central  anterior  opening'  to  represent  the  nrethra,  throngii 
Avhich  the  urethroscope  is  introduced;  make  tw^o  little  side  openings, 
placed  symmetrically,  to  represent  the  ureteral  orifices.  This  balloon 
is  attached  to  a  little  hoard,  and  thus  provides  means  of  exercise  at 
small  expense,  in  the  hei^'innino-s  of  cystoscopy.  By  cutting'  this  halloon 
lioiizontally  in  its  greatest  diameter,  the  desired  linage  may  he  drawn 
or  painted  in  its  lower  segment  and.  thus  studied  through  the  cystoscope. 
The  beginner  thus  learns  how  to  int(n"pret  cystoscopic  pictures,  this  be- 
ing the  greatest  difficulty  in  the  practice  of  cystoscopy.  This  practice 
is  especially  useful  in  prismatic  cystoscopy  for  the  images  are  con- 
siderably displaced  and  deformed,  varying  according  to  the  distance 
at  Avhich  the  prism  is  held,  and  so  forth.  With  these  vesical  phantoms 
the  l)eginner  wall  acquire  a  certain  degr(H'  of  experience  and  digital  skill 
which  is  so  essential  in  the  practice  of  cystoscopy  in  the  living  subject. 


CHAPTEK  V 
PEISMATIC  (INDIRECT)  CYSTOSCOPY 

The  indirect  vision  cystoscope  is  essentially  an  instrument  for 
vesical  exploration.  At  the  present  day,  its  nse  is  general  for  the 
examination  of  the  walls  of  the  bladder,  and  its  indications  are  many 
and  varied. 

Nitze's  Prismatic  Cystoscope. — The  prismatic  cystoscope  of  Nitze 
and  those  Avhich  are  derived  from  it  are  today  the  instruments  most 
connnonly  nsed  in  the  examination  of  the  vesical  cavity.  Nitze's 
instrmnent  consists  of  a  metallic  catlieter  with  one  extremity  bent 
like  a  crutch  (Fig.  106).  Its  caliber  corresponds  to  No.  21  Charriere, 
and  its  length  is  20  centimeters.  The  crutch-lilve  extremity  bears  a 
little  electric  lamp  designed  to  light  up  the  parts  corresponding  to 
the  concavity  of  the  instrument.  These  lamps  are  highly  i^erfected 
and  are  perfectly  cold  when  lighted,  at  least  when  new. 

Of  the  two  wires  that  bring  the  current  to  the  lamp,  one  is  insulated 
in  its  entire  length  in  the  wall  of  the  instrument;  the  other  is  con- 
nected Avith  the  metallic  wall  itself.  The  current  is  brought  to  the  in- 
strument by  means  of  a  pair  of  arms  in  the  form  of  a  double  fork  which 
is  apx)lied  by  simple  contact  to  two  rings  attached  to  the  neck  of  the 
cystoscope.  Because  of  this  arrangement  the  cystoscope  may  be  turned 
in  all  directions  Avithout  interrupting  the  electric  current.  The  eye- 
piece of  the  cystoscoiDe  presents  a  little  immovable  button  Avhich  con- 
stantly informs  the  observer  as  to  the  exact  position  of  the  prism. 

The  body  of  the  cystoscope  is  straight  and  its  extremity  is  bent, 
as  already  stated,  like  a  crutch.  At  the  elbow  thus  formed,  is  a  reflect- 
ing prism,  upon  which  are  reflected  the  images  of  those  portions  of  the 
bladder  which  are  illuminated  by  the  electric  lamp.  In  the  body  or 
shaft  is  a  series  of  lenses  which  magnify  the  image ;  these  lenses  make 
up  the  optical  system  of  Nitze. 

.  Nitze's  Optical  System. — This  consists  of  three  sets  of  lenses.  At 
the  vesical  extremity  is  a  compound  lens  generally  called  the  "objec- 
tive." This  furnishes  a  real,  inverted  image.  As  this  image  is  very 
small,  being  formed  at  a  close  distance  and  backward,  it  would  be  im- 
possible to  see  it  with  the  naked  eye.  That  is  why  a  second  lens  is 
XDlaced  behind  it  near  the  middle  of  the  shaft  or  body  of  the  cystoscope ; 


PKISMATIC    (iXKUIKCT)    CYSTOSCOPY  169 

tlio  iiuai^'c  is  thus  hroii.^lil  t'rom  the  vesical  cxti'diiity  of  llic  tiihc  to 
its  cxtorior  cxt  rciiiil y  (|iiil('  close  to  llic  so-cnlIc(l  "ociilai'."  Tlic  latter 
acts  only  as  a  strong-  iiia,i;iii Tying  glass,  that  is  to  say,  it  enlarges  the 
(lir(!ct  image  already  obtained. 

To  recapitulate:     Three  lenses  constitute  tlie  optical   system  (jT 


^ 


Fig.   106. — Nitze's   cystoscope. 

Nitze;  one  situated  at  the  vesical  extremity,  the  '' objective;"  the  sec- 
ond situated  at  the  middle  of  the  body  or  shaft,  and  the  third  is  the 
' '  ocular. ' ' 

To  this  optical  system  is  added   a    rectangular   prism,   which    is 
placed  in  front  of  tlie  objective.    This  prism  is  arranged  so  that  one  of 


Fig.  107. — Sectional  view  of  Nitze's  cystoscope  (Nitze).  a,  metallic  capsule  which  holds  the  lamp; 
b,  contact  wire  of  the  lamp  terminating  in  a  fine  spiral;  c,  metallic  part  into  which  the  lamp  is  screwed; 
d,   fine   insulated   platinum   plate,   which   makes   the   contact   with   the    spiral   wire,    h ;  e,    lens. 

its  surfaces  is  perpendicular  to  and  the  other  parallel  with  the  longi- 
tudinal axis  of  the  instrument,  with  which  the  hypothenuse  of  the  rec- 
tangular prism  must  form  an  angle  of  45  degrees.  The  hypothenuse 
presents  a  mirror  which  sends  back  the  luminous  rays  that  enter 
through  the  lateral  window  of  the  instrument. 


A' 


Fig.    108. — Optical   system   of   Nitze's   cystoscope. 


The  effect  of  this  prism  is  to  displace  the  visual  })laiu>  to  the  extent 
of  90  degrees.  It  is  because  of  this  pi-ism  that  the  images  obtained 
present  varied  irregularities,  alterations  and  displacements  Avhich  do 
not  give  an  entirely  exact  idea  of  the  real  appearance  of  the  objects 


170 


CYSTOSCOPY    AXD    rRETflEOSCOPY 


examined.  All  objects  placed  vertically  are  seen  in  the  horizontal 
plane,  and  on  the  other  hand,  what  is  really  horizontal  becomes  vertical. 
Moreover  what  is  in  front  is  seen  behind,  in  the  cystoscopic  pictnre,  and 
objects  that  are  located  superiorly  are  seen  inferiorly,  and  reciprocally, 
in  the  \^sual  field.  On  the  other  hand,  objects  situated  on  the  right  or 
left  side  are  seen  on  the  corresponding  side. 

In  addition  to  the  optical  system  and  the  prism,  the  cystoscope 
presents  a  lamp  i)laced  in  front  of  the  prism  at  the  ''beak,"  which  is 
joined  to  the  shaft  or  tube  at  an  obtuse  angle  based  on  the  so-called 
"Mercier's  crutch  curve."  At  the  ocular  end  of  the  cystoscope  are 
two  metallic  rings  isolated  one  from  the  other,  one  of  which  is  soldered 
to  the  metal  of  the  instrument  itself.  The  other  is  attached  to  the 
conducting  wire  which  penetrates  into  the  interior  of  the  shaft  by  a 
special  groove. 

The  Cystoscopic  Lamp. — The  lamp  is  situated  at  the  beak,  and 


Fig.    109. — Cystoscope    lamp    and    its   mounting. 

hooded  in  a  metallic  cap.  Its  free  extremity  constitutes  the  beak  of  the 
instrument,  while  the  other  end  presents  a  screw  by  means  of  which 
the  lamp  is  attached  to  the  shaft  of  the  instrument.  One  of  the  x3oles 
which  serve  to  bring  the  current  to  the  lamp  is  directly  in  contact  ^^^th 
the  metallic  hood  which  partially  covers  the  lamp.  The  other  is  rolled 
up  in  a  fine  spiral  and  brought  into  contact  with  the  interior  conducting 
^^ire  which  is  placed  in  the  shaft  of  the  instrument  and  which  it  follows 
in  its  entire  length.  At  this  point  the  current  frequently  fails  because 
of  poor  contact,  and  it  is  well  to  remember  that  the  condition  of  this 
little  spiral  must  be  investigated  when  a  lamp  will  not  Inirn.  By 
lengthening  this  spiral  with  a  pair  of  forceps,  a  better  contact  is  ob- 
tained. The  greatest  gentleness  must  be  emplo3'ed,  for  the  spiral  is 
extremely  fragile  and  breaks  easily. 

The  filaments  of  the  lamp  were  formerly  made  of  carbon,  but  they 
had  the  disadvantage  of  generating  a  great    deal    of    heat.     At    the 


PIMS.MATIC     (iXDIIM-X'T)     C'VSTDSCOPV 


171 


l)r<'sciit  lime,  willi  tlic  use  of  nictallic  rilaiiicnts  a  iiiitcli  more  iiilciiso 
illmiiiiia1i(»ii  is  (»l)taiiic(l  and  the  hinips  ai-c  aliiiosi  always  cold;  tlicy 
hccoiiic  warm  only  alter  ])r()l()iii;<'(l  use  {F'l'j;.  109). 

Rotating  Contact.- -Tlie  current  is  cai-riod  into  the  iiiU'iioi-  ol"  tlie 
cystosc()])c  l)\  iiicaiis  ol"  a  special  rotatin.i;-  contact  (pincers)  in  the 
sliape  of  a  fork  with  two  l)ranches  separated  one  froni  tlic  otlier  (Vvj;. 
110).  These  branches  ai-c  connected  Avitli  the  contact  riii^-s  of  the 
cystoscopy    In  the  center  ol'  the  lork  is  a  small  slide  hv  means  of  which 


Fig.    110. — Ordinary     attachment     of     the     indirect 
cystoscope. 


Fig.    111. — E.     Frank's     improved     attachment     for 
the    indirect    cystoscope. 


the  current  may  ])e  turned  on  or  ofC  at  will.  This  rotatin.u-  contact 
works  very  well  when  in  good  condition,  l)ut  if  not  inoperly  cared  foi', 
i.  e.,  permitted  to  get  dirty  or  rusty,  a  poor  contact  results. 

Frank,  of  B<'rlin,  has  moditied  this  pair  ol'  pincers  in  the  following 
maimer:  Instead  of  having  it  end  in  a  douhle  foi-k.  the  ])arts  move  in  a 
semicircle  Avhich  is  narrowed  or  widened  liy  the  aid  of  a  flat  ivory  bolt 
so  that  it  can  seize  the  cystoscope  firmly,  yet  allowing  the  latter  to  turn 


172 


CYSTOSCOPY   AND    URETHROSCOPY 


easily  in  its  grip.  Variations  and  interruptions  Avhieli  are  so  annoying 
during  an  examination  are  avoided  Avitli  this  instrument  (Fig.  111). 
Such  was  the  original  cystoscope  of  Nitze,  the  appearance  of  which 
soon  afterward  gave  rise  to  many  improvements.  Disregarding  for  the 
moment  those  changes  which  aimed  at  perfecting  ureteral  catheteriza- 
tion, or  the  treatment  of  vesical  tumors  or  of  foreign  bodies  in  the 
bladder,  we  shall  consider  in  this  chapter  only  those  improvements 
which  gave  a  better  view  of  the  vesical  walls,  A  full  consideration  of 
these  many  improvements  would  occupy  many  chapters,  but  we  shall 
study  them  briefly: 

1.  Modifications  for  obtaining  a  direct  view  of  objects. 

2.  Modifications  for  magnification  of  images  and  enlargement  of 
the  visual  field. 

3.  Modifications  for  irrigating  the  bladder. 

4.  Modification  for  securing  a  view  of  the  bladder  neck. 

5.  Modification  for  securing  binocular  vision. 

AB 


i;^ 

t 

Fig.   112. — Course  of  the  light  rays  in  the   Nitze-Frank  cystoscope. 


6.  Modification  for  securing  rectification  of  cystoscopic  images. 

7.  Modification  for  endovesical  ]Dhotograi3hy. 

8.  Modification  for  ureteral  catheterization. 

9.  Modification  for  endovesical  operations. 

10.  The  pancystoscope  of  Baer. 

1.  Modifications  for  Obtaining  a  Direct  View  of  Objects. — Tlie  first 
experiments  made  with  the  object  of  correcting  the  deformities  pro- 
duced by  the  cystoscope,  were  made  by  Weinberg,  in  1906,  and  by 
Frank,  in  1907.  In  1906  the  former  devised  liis  "orthokystoscop,"  in 
which  the  correcting  lens  was  placed,  not  in  the  shaft  of  the  instrument, 
but  in  a  separate  mounting  affixed  to  the  ocular.  But  this  instrument 
only  permitted  the  examination  of  a  part  of  the  base  of  the  bladder 
and  of  the  nearest  portion  of  its  circumference. 

Ernest  Frank's  cystoscope  which  appeared  in  1907^  is  character- 
ized essentially  by  the  presence  in  the  optical  apparatus  of  a  second 


PRisMATrc   (indirect)   cystoscopy 


173 


prism,  wliicli  coitccIs  llic  iin'ci'lcMl  iin;i,i;('  in  ilic  lii'st  pi'isiii  (Fift'S.  118 
and  114).  Tliis  corrective  optical  syslcin  may  he  adapted  to  all  cyslo- 
scopes  ill  tlie  fonii  of  a  movable  moiiiiliii.i;-  a(laj)l('(l  to  ilic  ocular  so  lliat 


Fig.    113. — Cystoscopic    image    in    the    early    cystoscopes    (inverted). 

neither  the  outer  appearance  of  the   instrument   nor  the   customary 
manner  of  use  need  be  modified  in  the  least  degree.    With  this  cysto- 


Fig.    114. — Cystoscopic   image   corrected   in    Frank's    new   cystoscope.      Double    catheterization   of   the    ureters. 

scope  the  real  appearance  of  the  entire  bladder  can  be  studied  without 
inversion  of  the  image,  and  besides,  the  illumination  is  very  bright. 
2.  Modifications  for  Magnifying  the  Image. — In  1909,  Otto  Ring- 


Fig.   115. — Course  of  the  light  rays  in  a  cystoscope,  witli   Ringleb's  system. 

1(^1),  of  Berlin,  devised  a  special  optical  systcMii  constructed  on  tlie  ty])(' 
of  the  telescope  (Fig.  115);  this  instrument  should  i)ropeiiy  be  raugiMl 
with  microscopes  of  the  immersion  type  and  with  slight  magnihcation. 


174  CYSTOSCOPY    AND    UEETHEOSCOPY 

This  oiDtical  system  corrects  tlie  inverted  image  and  obtains  this  result 
by  means  of  two  corrective  arrangements  combined  with  a  prism  in  the 
form  of  Amici's  "roof"  or  "garret"  (Fig.  116).  Throngh'^this  ar- 
rangement, erect  and  true  pictures  are  obtained.  Ringieb's  cystoscope 
has  a  large  visual  field  and  joroduces  cystoscopic  j)ictures  of  great 
clarity.  Unfortunately  this  instrument,  which  is  very  exj^ensive,  finds 
its  greatest  utility  when  it  is  desired  to  make  a  minute  examination  of 
the  details  of  a  given  point  in  the  bladder.  Quoting  Hogge, 
^^^  of  Liege,  "as  compared  with  the  analogous  instrument  of 

^V^k        Nitze,  the  visual  field  is  smaller,  but  what  is  seen,  is  seen 
^^^     admirabh'. " 
^H  The  cystoscope  of  AVilliam  Otis,  of  New  York,  was  de- 

^      vised  in  order  to  olitain  a  large  visual  field.     In  this  in- 
X       strument  the  prism  is  replaced  by  a  hemispherical  lens  the 
___/  flat  surface  of  Avhich  is  silvered.     The  substitution  of  this 

Fig.  116.—      bomispherical  lens   is   ecpiivalent  to   the   addition   of  two 

Amici's  prism,  f>Ti  ii  •  -\ 

in  the  form      plauocouvex  leuses ;  ot  the  latter,  the  lens  occupvmg  the 

of  a   housetop.  .  „  .  x  .         ■ 

upper  portion  of  the  prism  assembles  the  rays  at  a  large 
angle  and  brings  them  together  on  the  hypothenuse ;  the  other  on  the 
anterior  surface  of  the  prism,  corresponds  to  the  first  lens  in  the  tele- 
scope. Otis  obtained  a  visual  field  four  times  greater  than  that  ob- 
tained with  any  other  rectangular  cystoscope ;  in  addition,  the  picture 
is  also  very  clear. 

3.  Modifications  for  Bladder  Irrig-ation. — It  being  absolutely  nec- 
essary that  the  bladder  contents  shall  be  perfectly  transparent  in  or- 
der to  practice  cystoscopy,  and  since  the  presence  of  pus  or  blood'may 


Fig.   117. — Brenner's    cystoscope. 


cloud  the  bladder  fluid,  many  efforts  have  been  made  to  remedy  this 
inconvenience.  Many  authors  have  devised  instruments  with  the  ob- 
ject of  permitting  bladder  irrigation  during  the  cystoscoiDic  exam- 
ination. 

BRE:N'iSrER/'s  Cystoscope. — Brenner's  Avas  the  first  cystoscope  (Fig. 
117)  in  which  the  visual  field  and  the  lamp  were  situated  on  the  convex- 


PniS.MATlC    (  I  xdiiikct)    cvstoscopv  175 

iiy  of  llic  hcak.  I'liis  insl  rniiiciil  was  |)r()\i(l(Ml  willi  a  small  lulx'  on  its 
convex  side  fof  llic  ii'ii,i;ali()ii  of  llic  hiaddcr  diirin.^-  Ilic  <'ystosfo])i(' 
cxaiiiiiialioii.  lii  addition,  this  canal  alliiou,a,li  oL'  line  calilxM'  was  in- 
tended to  afford  facility  for  tiie  passa^'e  of  a  ureteral  catlietei". 

Mkcai.oscopk  ov  Botsseau  dit  Rocher. — Tills  author-  devised  a  cyst- 
()sc()])('  wirn-li  lie  called  a  '•nieij,-aloscoi)e,"  It  was  conipose(l  of  two  se])- 
arate  parts.  One  consisted  of  a  hollow  catheter  of  No.  23  Charriere  cal- 
iber, elltowed  near  its  extremity  and  provided  at  this  point  with  a  very 
small  electric  lamp;  the  second,  or  optical  portion,  which  slipped  into 
and  ])enetrated  the  first,  comj^rised  a  tul)e  wliicli  contained  lenses  and 
a  i3rism.  The  latter  was  arranged  in  such  a  manner  tliat  it  fitted  into 
a  window  prepared  for  this  purpose,  in  the  hollow  catheter  just  men- 
tioned. AVhen  the  first  portion  was  introduced  into  the  bladder,  with- 
out the  optical  portion,  vesical  irrigation  was  possil)le  as  with  an  or- 
dinary catheter.  Later,  Boisseau  du  Tvoclier'''  added  two  little  irrigation 
tul)es  to  the  convex  portion  of  his  instrument  Avhich  serve  to  irrigate 
the  bladder  during  the  examination  and  also  facilitate  the  passage  of 
ureteral  catheters. 

Guterbeock's  Cystoscope. — This  author's*  instrument  strongly  re- 
sembles the  megaloscope  of  Boisseau  du  Rocher.  As  in  the  preceding, 
the  catheter  and  the  optical  apparatus  are  independent  of  each  other, 
which  facilitates  bladder  irrigation  during  the  examination  when  the 
optical  portion  is  removed.  The  catheter,  slightly  elbowed  at  its  ves- 
ical extremity,  was  pierced  by  two  orifices  tlirough  Avhich  the  bladder 
was  irrigated.  In  the  interior  of  this  catheter  a  tube  bearing  the  lamf), 
the  prism,  and  the  optical  system,  was  inserted.  The  lamp  and  the 
prism  were  thus  placed  exactly  at  the  opening  in  the  catheter. 

Fexwick's  Cystoscope. — This  instrument,  based  on  the  same  prin- 
ciple as  Guterbrock's,  is  an  improvement  on  the  latter.  It  is  likewise 
composed  of  two  distinct  parts.  The  holloAv  sound  differs  from  the  pre- 
ceding instrument'  in  that  it  bears  only  one  large  oriiice  (instead  of 
two),  thus  iDermitting  l)la(lder  irrigation.  During  the  examination,  the 
lamp  and  prism  are  brought  to  this  point  and  maintained  there.  The 
cystoscope  of  Kollmami,  of  Leipzig,  is  also  constructed  according  to 
these  principles. 

All  of  these  instruments  come  under  the  category  of  irrigating 
cystoscopes,  of  which  every  urologist  ought  to  possess  at  least  one 
model,  for  they  are  indispensal)le  in  very  many  circumstances.  They 
may  be  referred  to  a  model  type  which  consists  of  a  hollow  sound,  el- 
l)()wed  in  the  form  of  a  crutch,  Avith  an  oi)ening  near  the  elbow  through 
which  water  iiiav  he  inti-oduced  into  the  ])la(l(ler  and  withdrawn  at  will. 


PLATE  X 

Fig.  1. — Normal  appearance  of  the  bladder  neck  as  seen  with  the  direct 
vision  cystoscope.  The  first  ling  represents  the  end  of  the  urethra; 
the  dark  central  portion  represents  the  darkened  base  of  the  bladder. 

Fig.  2. — Cicatrix  of  a  vesical  perforation  due  to  the  rupture  of  an  abscess 
in  the  vicinity  of  the  bladder. 

Fig.  3. — Large  papillomatous  tumors  of  the  bladder  neck. 

Fig.  4. — Application  of  the  galvavocaatcry  to  the  tumor  at  the  lower  part 
of  the  bladder  neck  (compare  this  with  Fig.  3). 

Fig.  5. — Appearance  of  a  normal  ureteral  orifice. 

Fig.  6. — Normal  emission  of  the  right  ureter  as  seen  with  the  direct  vision 
cystoscope.  In  this  case,  the  cystoscoj^ic  tube  is  held  in  profile,  and  not 
in  full  view.  The  urine  is  thus  observed  leaving  the  ureter  in  the  form 
of  a  little  jet  of  water. 


-9% 


Fig.  1. 


Fig.  2. 


Fig.  3. 


Fig.  4. 


Fig.  5. 


Fig.  6. 


PLATE  X 


PRISMATIC    (indirect)    CYSTOSCOPY  177 

Jn  llic  iiilci'ioi-  of  lliis  liollow  sound  an  oLlui-nloi-  is  inserted,  carrying 
a  ])risiu  and  optical  system,  in  oi-dci-  lliat  the  optical  obturator  (tel- 
escojje)  may  be  introduced  while  tlie  l)ladder  is  full  of  water,  a  bolt 
with  an  automatic  valve  is  provided  (Fig.  118). 

Ti-rio-ating  cystoscopes  often  render  the  greatest  service,  particu- 
larly in  the  examination  of  a  tumor  of  the  bladder  which  bleeds  freely; 
the  liemoi-rhage  thus  produced  in  these  cases  would  otherwise  make  a 
clear  view  impossible.  The  technic  employed  with  the  irrigating  cysto- 
scoj^e  is  as  follows:  The  bladder  is  cleansed  through  an  ordinary  cath- 
eter, with  Avarm  boric  solution.  The  cystoscope  is  introduced  and  an 
effort  is  made  to  see  clearly.  If  the  vesical  region  is  found  obscured 
by  the  presence  of  pus  or  blood,  the  optical  piece  in  the  interior  of  the 
tube  is  Avithdrawn  and  a  little  rubber  joint  mounted  on  a  metallic  piece 
is  inserted  in  its  place,  which  permits  temporary  occlusion  of  this  tube. 
The  unclean  fluid  is  alloAved  to  run  out  and  clear  fluid  is  injected  to  re- 


Fig.  118. — Automatic  valve,  in  irrigating  cystoscopes,  which  can  be  opened  for  the  insertion  of  the 
optical  part,  and  when  this  is  withdrawn,  it  closes  automatically,  thus  preventing  the  escape  of  the  bladder 
fluid. 

place  it.    The  metallic  piece  is  now  removed,  the  optical  system  (tele- 
scope) is  reintroduced  and  the  examination  is  continued. 

This  arrangement  has  notable  advantages,  especially  A\dien  we  are 
dealing  with  prostatic  lesions  or  with  a  congested  prostate  which  bleeds 
on  contact  Avitli  the  instrument.  Furthermore,  once  the  prostate  has 
been  jDassed,  there  is  no  further  bleeding  after  the  instrument  has  en- 
tered the  bladder..  Unfortunately,  in  spite  of  these  really  important  im- 
])rovements,  it  is,  nevertheless,  true  tliat  in  a  great  many  cases  renal 
or  vesical  bleeding  prevents  a  clear  view  with  the  prismatic  cystoscope ; 
in  these  instances,  direct  vision  cystoscopy  must  be  resorted  to. 
4.  Improvements  for  Viewing  the  Bladder  Neck. — 
Nitze's  Vesical  Cy.stoscope  Xo.  3. — In  order  to  olitain  a  view  of 
the  vesical  neck,  Nitze  devised  a  special  model  Avitli  a  modified  elbow 
wliidi  lie  called  ''cystoscope  No.  3;"  with  this  instrument  the  vesical 
neck  could  be  seen  easily. 

ScHLACiiNTWEix's  Cystoscope. — 'I'his  autlior'  later  solved  the  diffi- 
cult problem  of  obtaining  a  direct  vicnv  of  the  bladder  neck  by  adopt- 


178 


CYSTOSCOPY   AISTD    l^EETHEOSCOPY 


ing  a  movable  prism  controlled  from  witliont  (Fig.  119).  By  means  of 
a  special  mechanism  the  prism  can  be  projected  forward  and  thus  a 
retrograde  view  of  the  bladder  neck  can  be  obtained.  Throngli"  a  very 
simple  maneuver  the  prism  is  made  to  return  to  its  original  position. 
Thus  this  instrument  may  serve  not  alone  for  the  inspection  of  the 


Fig.    J 19. — Schlagintweit's    cystoscope. 


vesical  neck,  but  also  for  the  examination  of  the  entire  bladder  like  a 
cystoscope  with  the  ordinary  prism. 

5.  Improvements  for  Securing  Binocular  Vision. — In  order  to  ob- 
tain a  view  of  an  ol^jcct  situated  in  the  bladder  with  l)oth  eyes  and  thus 


Fig.   121. — Sectional  view   of   Kutner's   cystoscope. 


secure  the  relief  furnished  by  binocular  vision,  Jacoby,*"  of  Berlin,  de- 
vised a  stereocystoscope  through  which  the  bladder  can  be  seen  with 
both  eyes.  This  method  of  examination  greatly  facilitates  the  proper 
interpretation  of  the  images,  especially  for  beginners. 


PRISMATIC     ( INDIRECT )    CYSTOSCOPY 


179 


Kutner's  ])EMO]srsTRATioi>r  Apparatus. — In  order  to  pormit  two  ob- 
servers to  examine  the  bladder  simultaneously,  Kutner  devised  an  ap- 
paratus which  may  be  adapted  to  the  eystoseope  (Figs.  120  and  121). 
This  apparatus  consists  of  a  bifurcated  tube  which  is  attached  to  the 
ocular  of  the  eystoseope.  At  the  point  of  intersection  of  the  axis  of  the 
long'  and  short  tubes,  a  little  trans])arent  mirror  is  inclined  at  an 
angle  of  30  degrees  with  the  axis  of  the  tube.  The  mirror  divides  the 
luminous  rays  into  two  parts.  One  portion  traverses  the  mirror  and 
finally  strikes  the  optical  apparatus  of  the  short  tube;  the  other  is 
reflected  by  the  mirror  into  the  long  tube.  The  images  seen  by  both 
observers  are  comparatively  clear  and  clean-cut. 

6.  Modifications  for  Rectification  of  the  Image. — 
Jacoby's  Corrective  Mounting. — During  the  cystoscopic  examina- 
tion, the  images  perceived  are  invariably  considerably  displaced  as 


Fig.   122. — Jacoby's   corrective    mounting. 


compared  with  the  real  position  of  the  objects  themselves.  In  order  to 
obviate  this  condition,  Jacob}^  devised  a  corrective  apparatus  (Fig. 
122)  by  means  of  which  the  real  position  of  the  objects  in  the  cysto- 
scopic picture  can  be  determined.  Tliis  api^aratus  is  attached  by  means 
of  a  screw  in  front  of  the  ocular  of  the  cystoscopes  ordinarily  used.  It 
consists  of  a  rotary  prism  which  is  easily  turned,  a  vertical  dial  which 
oscillates  on  a  circular  disc  divided  into  degrees  and  another  situated 
behind  the  dial  and  provided  with  a  button.  By  rotating  the  corrective 
prism  the  exact  situation  of  objects  is  easily  found  with  this  axjparatus. 
7.  Modifications  for  Endovesical  Photography. — The  beautiful  pic- 
tures seen  with  the  eystoseope  long  ago  inspired  attempts  at  j)hotog- 
raphy  for  permanent  record.     The  first  photographic  attemiDts  made 


180 


CYSTOSCOPY    AND   URETHROSCOPY 


by  Antal,  at  Budapest,  and  by  Kntner,  were  not  satisfactory,  Mtze^ 
perfected  the  method  and  obtained  highly  satisfactory  results.  Im- 
portant improvements  were  subsequently  made  by  Hirschmaifn,  and 
later  by  Berger.^  One  of  the  most  practical  methods  of  photography  is 
that  of  Kollmann,  of  Leipzig  (Fig.  123).  Jacoby,  of  Berlin,  subse- 
quently perfected  a  stereocystograph,  with  which  stereoscopic  images 
of  objects  situated  in  the  bladder  can  be  obtained. 

8.  Modifications  for  Ureteral  Catheterization. — The  modifications 
having  this  object  in  view  are  fully  described  in  a  later  chapter. 

9.  Modifications  for  Endovesical  Operations. — These  changes  are 
also  described  later  (See  Treatment  of  Bladder  Tumors). 

10.  Baer's  Pancystoscope. — Baer,  of  A¥iesbaden,  comprised  the 
principal  modern  improvements  contributed  to  cystoscopy  in  one  in- 
strument which  he  named  the  ''universal  instrument"  or  "pancysto- 
scope." It  consists  of  a  tube  in  which  the  movable  optical  portion  of 
the  various  cystoscopes  is  inserted.    With  this  instrument  it  is  a  simple 


Fig.    123. — Kollmann's   photographic   cystoscope. 


matter  to  substitute  one  optical  system  for  another  or  to  introduce  into 
the  tube  a  series  of  instruments,  such  as  catheters  for  the  bladder  and 
ureters,  galvanocautery  handles,  forceps,  curettes,  etc. 

This  instrument  has  very  distinct  advantages,  for  it  makes  possible 
the  use  of  ureteral  catheters  of  rather  large  caliber,  No.  9,  Charriere, 
for  example.  It  also  enjoys  all  the  advantages  of  the  irrigating  cysto- 
scope. Lastly  it  makes  endovesical  operations  possible.  Unfortu- 
nately, it  is  really  not  very  practical,  because  it  is  too  complicated  and 
deteriorates  easily. 

REFEREI^CES 

iFiank:     Trans.  Assn.  franq,.  d 'Urologie,  1907,  p.  452. 

-Boisseau  du  Eocher:     Ann.  d.  Mai.  d.  org.   genito-uiin.,  1890;  De  1 'endoscopic  a  lumiere  ex- 

terne  et  de  I'endoscopie  a  lumiere  interne,  Ibid.,  1892,  p.  413;  Ibid.,  1894,  p.  51. 
-Boisseau  du  Rocher:     Cystoscopie  et  catheterisme  des  ureteres,  Ann.  d.  mal.  d.  org.  genito- 

urin.,  1898. 
iGuterbrock:     Berl.  klin.  Wchnschr.,  1895,  No.  29,  p.  628. 


TECHNIC   OF    INDIRECT   VISIOIsr    CYSTOSCOPY 


181 


!"'S('lil;i^iiil  w(^i(  :      Dus    rctifi^riKic    Kystnskop,    fciif  r;illil.    I',    d.    Kiaiikli.    d.    Ifjirii  u.    Scx.-Or^., 

190;;,  xiv,  1).  202. 
•iJacoby:     Lc  Stcroocystoscopc,  Ann.  gonito-urin.,  March  1,  1906,  p.  359. 
7Nitze:     Kystophotosi'aphisclu'r  Atlas,  Wiosbaclcn,  1894. 
«Bcrgcr:     Notice  sur  la  photograxiliic  dc  la  vessic,  Ann.  gcnito-uriii.,  1900,  p.  414. 


TECHNIC  OF  INDIRECT  VISION  (PRISMATIC) 
CYSTOSCOPY 

Sterilization  of  the  Cystoscope. — Tlio  prismatic  cystoscope  sliould 
l)e  sterilized  in  a  formalin  sterilizer,  of  which  I  have  described^  one  of 
the  most  simple  and  practical  types  (Fig.  124).  Tliis  apparatus  con- 
sists of  a  simple  tul)e  of  large  caliber,  open  at  both  ends,  and  carrying 
at  each  end  a  metallic  furrow,  upon  which  is  screwed  a  perforated 


Fig.   124. — Formaldehyde   sterilizer. 

metallic  stopper  provided  with  a  ferule.  At  one  extremity  a  rubber 
tube  is  fastened,  which  connects  the  glass  tube  to  a  bottle  filled  with 
])ure  formol;  at  the  other  extremity  is  a  rubber  tube  in  direct  con- 
nection Avith  a  water  spigot. 

This  apparatus  is  extremely  simple.  By  opening  the  water  tap, 
a  vacuum  is  created  in  the  sterilizing  tube  whicli  takes  up  the  air  that 
comes  bubbling  up  into  the  formol  and  becomes  charged  with  formalde- 
hyde vapor.  This  vapor,  constantly  fresh  and  continually  renewed, 
completely  sterilizes  the  instruments  contained  in  the  interior  of  the 
tube  in  fifteen  minutes. 

The  great  advantage  of  this  principle  of  sterilization,  which  was 
devised  by  Suarez  de  Mendoza,  of  IMadrid,"  is  that  in  addition  to  its 


182  CYSTOSCOPY   A]<rD    URETHROSCOPY 

complete  secimty  from  the  point  of  view  of  disinfection,  it  is  abso- 
lutely harmless  to  the  instruments,  however  delicate  they  may  be.  It 
is  indeed  well  known  that  when  prismatic  cystoscopes  are  allowed  to 
remain  in  a  trioxymethylene  (iDaraform)  sterilizer,  the  optical  portion 
undergoes  changes  Avliich  render  them  unfit  for  service.  With  this 
apparatus,  to  the  contrary,  instruments  never  undergo  the  slightest 
change  as  a  result  of  the  sterilization;  this  is  accomplished,  as  above 
mentioned,  in  fifteen  minutes. 

Cystoscopy  is  best  performed  in  a  darkened  room.  The  c^^stoscopic 
pictures  will  thus  be  found  much  clearer  and  brighter. 

Preparation  of  the  Cystoscope. — The  instrument  should  be  tried 
before  it  is  sterilized  and  the  operator  should  be  certain  that  all  its 
parts  are  in  good  condition. 

1.  Testiis^g  the  Optical  Apparatus. — The  visual  field  of  the  in- 
strument should  be  very  clear  and  should  give  exact  and  precise  im- 
ages. The  prism  and  the  ocular  should  be  in  perfect  condition  and  their 
surfaces  brilliant  and  dry.  The  outer  surface  of  the  prism  or  of  the 
lens  is  occasionally  affected  by  moisture.  When  this  is  only  on  the 
outside,  it  is  easily  remedied  by  cleaning  the  glass  with  a  fine  cloth  or 
with  chamois.  When,  however,  the  moisture  has  penetrated  into  the 
interior  of  the  cystoscope,  and  has  reached  the  inner  lens,  the  cysto- 
scope must  be  repaired  so  that  perfect  clarity  of  the  lenses  and  prism 
may  be  assured. 

In  cystoscopes  with  a  movable  ofjtical  system,  the  latter  possibly 
may  not  correspond  exactly  with  the  window  of  the  instrument  into 
which  it  is  inserted.  This  verification  should  be  made  before  the 
cystoscope  is  used. 

2.  Testing  the  Electric  Current. — The  lamp  should  give  a  good 
white  light.  The  intensity  of  the  current  should  be  increased  until  it 
is  no  longer  possible  to  distinguish  the  handle  of  the  metallic  filament 
in  the  single  mass  of  light.  When  the  lamp  does  not  light  up,  the  cause 
should  be  sought;  first,  at  the  source  of  the  current,  next,  at  the  con- 
ducting wires,  and  then  at  the  rotating  contact  of  the  cystoscope.  At 
the  last  mentioned  point,  there  are  two  especially  delicate  places.  One 
is  the  interrupter,  where  the  groove  or  slide  may  be  somewhat  loos- 
ened, thus  preventing  the  transmission  of  the  current.  The  interrupter 
may  be  dirty  or  rusty  or  perhaps  some  dust  has  slipped  under  it.  These 
parts  must  be  cleaned  scrupulously.  When  the  current  does  not  pass, 
a  little  pressure  on  the  interrupter  will  produce  an  illumination,  which 
ceases  as  soon  as  the  pressure  is  released. 

The  second  cause  of  interruption  of  the  current  at  the  rotating 
contact  is  found  when  the  conducting  wires  at  this  point  are  loosened 


TECHNIC    OF    IXDIIIKCr    \ISI()X    CYSTOSCOPY 


183 


or  l)rok('ii.  Slioi'l  iiitcri'iiplioiis  of  llic  (•uitciiI  arc  produced  wliicJi 
result  in  a  llickcriii,!;-  of  llic  li,L;li1,  lliiis  makiii.L:-  the  examination  ex- 
tremely annoying.  At  t]ie  least  movement  the  lamp  goes  out,  only  to 
])econie  relighted  ijnmediately,  and  it  is  ntterly  impossible  to  make  a 
satisfactory  examination  in  these  circunistances.  A  x)oor  contact  he- 
tween  llie  arms  of  llic  coiiiacl  and  llic  I'iiigs  of  llie  cystoscope,  may  also 
produce  this  condition.  These  ti'oubles  are  best  avoided  by  keeping  the 
instrument  and  its  attachments  in  a  state  of  perfect  cleanliness  and 
repair. 

The  interior  conducting  Avires  also  should  lie  tested  and  vci-ified; 
likeAvise,  the  lamp  itself,  by  loosening  the  lani]),  and  bringing  it  in  con- 
tact Avith  the  Uxo  branches  of  the  contact.    If  this  is  in  good  condition, 


Fig.    125.- — Indirect    (prismatic)    cystoscopy;    position    of    operator    and    patient. 


illumination  should  result  immediately.  It  is  also  Avell  to  assure  one- 
self that  the  lamp  is  quite  cold,  and  ayIII  not  burn  the  vesical  mucosa. 

Preparation  of  the  Patient. — All  the  clothing  but  his  shirts  should 
be  removed;  he  should  lie  on  his  back,  the  knees  bent  and  wide  apart, 
the  feet  resting  on  stirrups,  the  buttocks  slightly  raised  and  brouglit  to 
the  edge  of  the  examination  table. 

Before  the  examination,  the  operator  should  have  made  certain 
that  the  urethra  is  permeable  Avitli  an  olivary  bougie,  No.  23.  If  stric- 
tures are  present,  they  should  he  dilated  before  anything  further  is 
done.  The  bladder  should  have  a  capacity  of  at  least  80  e.c,  and  even 
with  this  mininunn  capacity,  vision  is  almost  always  difficult.     It  is  a 


184  CYSTOSCOPY   AI^D    URETHROSCOPY 

well-established  principle,  therefore,  not  to  attempt  cystoscopy  in  an 
inflamed  bladder  without  having  submitted  it  previously  to  appro- 
priate  treatment  so  as  to  increase  its  capacity. 

When  an  immediate  examination  is  necessary,  it  Avill  be  well  to 
diminish  the  sensitiveness  of  the  bladder  by  instilling  into  it  two  grams 
of  antipyrin  and  ten  to  tAvelve  drops  of  laudanum  half  an  hour  be- 
fore the  examination.  Local  anesthesia  obtained  by  the  use  of  a  sterile 
1  per  cent  solution  of  stovaine  in  the  bladder,  will  also  be  useful,  but 
one  should  not  depend  too  much  on  its  effect.  As  a  last  resort  general 
chloroform  anesthesia  may  have  to  be  emplo^^ed. 

Finally,  the  vesical  medium  must  be  transparent.  Copious  irriga- 
tion with  tepid  boric  solution  until  it  returns  perfectly  clear  will  bring 
this  about. 


Fig.   126.- — Application   of  the   indirect   cystoscope    (Nitze). 

In  hematuria  of  vesical  origin,  irrigation  with  hot  boric  solution 
often  stops  the  bleeding  long  enough  for  the  examination  to  be  made. 
In  more  obstinate  cases,  recourvse  may  be  necessary  to  a  5  per  cent  so- 
lution of  antipyrin  of  which  40  to  60  grams  are  instilled  into  the  blad- 
der and  allowed  to  act  on  the  vesical  mucosa  for  some  minutes  before 
the  examination.  Two  or  three  instillations  of  the  following  solution 
may  be  made,  taking  the  precaution  not  to  let  it  remain  in  the  blad- 
der longer  than  a  few  minutes: 


Antipyrin 

40  gm. 

1:1000   solution  of  adrenalin 

100  drops 

Distilled  water 

1,000  gm. 

Occasionally  it  will  be  necessary  to  use  the  irrigating  cystoscope 
and  to  renew  the  bladder  fluid  several  times  during  the  examination. 


TECHNIC    OF    IXI)IIJE(,'T    VISION    CYSTOSCOPY 


185 


Fig.    127. — First   step   in   the   introduction    of  the   indirect   cystoscope.      The   instrument   is    inserted   into   the 

urethra  parallel  to  the  inguinal  fold. 


JFig.   128,. — Second  step   in  the  introduction  of  the   indirect  cystoscope.      The   instrument  and  the  p^nis  are 
held  in  a  plane  perpendicular  to  the  axis  of  the  pelvis. 


186  CYSTOSCOPY    AISTD    URETHROSCOPY 

Technic. — The  operator  begins  by  filling  the  bladder  with  warm 
boric  solution  or  simply  sterile  water,  avoiding  the  introduction  of  air 
into  tlie  bladder.  [In  the  United  States,  a  popular  medium  ft)r  filling 
the  bladder  is  a  solution  of  1 :5000  of  oxycyanid  of  mercury.  This  is 
sterile,  antiseptic,  and  nonirritating. — Editor.]  The  quantity  of  fluid 
in  the  bladder  should  average  between  150  and  200  c.c.  Too  much  fluid 
might  cause  distention  of  the  vesical  walls  and  in  consequence  would 
increase  the  distance  to  the  object  to  be  examined;  if  on  the  contrary, 
insufficient  fluid  is  injected,  the  walls  of  the  bladder  would  be  brought 
too  near  the  beak  of  the  instrument  and  tliis  would  prevent  the  easy 
manipulation  of  the  beak,  and  thus  obscure  the  view. 

IntroductiojSt  of  the  Cystoscope. — The  slightest  traumatism  pro- 
duced in  the  introduction  of  the  cystoscope  is  sufficient  at  times  to  pro- 
voke a  hemorrhage.  If  the  bleeding  obscures  the  prism,  which  is  quite 
certain,  it  will  surely  mar  the  clearness  of  vision,  whether  the  blood 
clouds  the  vesical  fluid  or  merely  because  of  a  little  blood  clot  adherent 
to  the  prism;  in  either  event,  the  visual  field  is  obscured.  The  cysto- 
scope should  be  introduced  into  the  urethra  and  bladder  delicately, 
slowly,  and  gently.  The  accompanying  illustrations  will  readily  show 
the  necessary  maneuvers  in  the  introduction  of  the  instrument.  Sev- 
eral distinct  steps  may  be  recognized: 

First  Step. — The  operator  places  himself  at  the  left  of  the  patient, 
holds  the  cystoscope  in  his  right  hand,  takes  hold  of  the  penis  with  his 
left  hand  and  raises  it  so  as  to  obliterate  the  penoscrotal  angle.  The 
beak  of  the  instrument  previously  lulnicated  with  sterile  glycerin  en- 
ters the  "meatus  and  gently  follows  the  entire  penile  portion  of  the 
urethra,  taking  as  its  guide  the  inguinal  fold,  to  which  the  penis  and 
cystoscope  are  made  parallel  (Fig.  127).  The  gradual  introduction  of 
the  cystoscope  is  made  evident  by  the  indicator  button  on  the  ocular 
of  the  instrument.  In  this  first  step  the  button  indicator  should  like- 
wise be  directed  towards  the  inguinal  fold. 

Second  Step. — As  with  the  introduction  of  a  sound,  the  second  step 
consists  in  bringing  the  cystoscope  and  the  penis  back  to  the  median 
line,  in  a  plane  perpendicular  to  the  pelvis  (Fig.  129).  The  penis  is 
still  held  in  the  left  hand,  and  the  cystoscope  descends  into  the  urethra 
by  its  own  weight  so  that  the  beak  engages  the  membranous  portion 
of  the  canal. 

Third  Step. — The  fully  extended  penis  is  now  gradually  lowered 
until  the  cystoscope  is  depressed  slightly  below  the  horizontal  (I'ig. 
130).  At  this  moment  the  operator  takes  hold  of  the  penis  and  the 
cystoscope  with  the  right  hand,  while  the  left  hand  makes  flat  pres- 
sure on  the  pubic  region.     This  loAvers  the  suprapubic  ligament  and 


TECTTNTC    Ol"    IN'DIIIKCT    VISION    CYSTOSCOPY 


18" 


Fig.    Ijy. — Tliird  steji   in  the  introduction  of  the  indirect  cystoscope.      The  left  hand   draws  the   penis 
upward,   while   the   right   hand  holds   the   instrument  vertically   and   perpendicular   to    the   axis    of   the   pelvis.^ 


Fig.  130. — F'ourth  step  in  the  introduction  of  the  indirect  cystoscope.  The  instrument  and  the 
penis  arc  depressed  between  the  thighs  of  the  patient;  the  righ^:  hand  gently  inserts  the  instrument;  the 
left   hand   makes  pressure  in   front   of   the   jiubic   region,   su   as   to   lower   the  subi'ubic   ligament. 


PLATE  XI 

Fig.  l.—Sillc  thread  seen  in  the  bladder.  This  silk  thread  was  used  for  a 
vesicovaginal  fistula  following  childbirth.  It  is  curious  to  observe  that 
the  knot  is  found  on  the  vesical  side  and  not  on  the  vaginal  aspect 
where  it  was  originally  tied. 

Fig.  2.— Syphilis  of  the  Madder,  showing  bullous  edema  of  the  vesical  mu- 
cosa. This  condition  seen  in  a  patient  of  Jeanselme,  came  on  coin- 
cidently  with  a  secondary  syphilis.  While  the  patient  still  presented 
the  roseola,  she  consulted  me  because  of  cloudy  urine,  and  I  found  the 
lesions  presented  in  this  illustration.  Examination  made  fifteen  days 
later,  during  which  time  specific  treatment  had  been  given,  showed  that 
the  bladder  was  restored  to  the  normal  condition. 


Fig.  1. 


Fig.  2. 

PLATE  XI 


DIFFICULTIES   OF   PRISMATIC    CYSTOSCOPY  189 

])('i-iiiils  tlie  cystoRCOiDe  to  slij)  casil}'  iiilo  IIk-  prostatic  region  as  far  as 
tlic  l)]adder.  Tlial  the  instniineiit  is  in  the  Madder  is  shown  when 
its  beak  can  Ix'  lotatcd  freely  without  any  resistance  being  felt.  Tlie 
i^ix'atost  difificiilties  ai'e  eiicoiuitei-ed  Ix'tweeii  the  second  and  third  steps, 
])artieuUirly  in  eases  of  tuberculosis  and  hy})erti'0])liy  of  the  prostate. 
Once  the  cystoscope  has  been  introduced  into  the  bladder,  the  ro- 
tating contact  which  carries  the  current  is  attached  to  the  instrument, 
and  the  lamp  is  lighted.  The  latter  should  always  be  kept  away  from 
the  vesical  wall  and  should  never  touch  it  directly.  The  complete  ex- 
amination of  the  bladder  is  then  made. 

REFERENCES 

iLiiys:     La  Clinique,  July  13,  1900,  p.  453. 

-SiKiiez  (le  Mendoza:     Trans.  XIV  Inteniat '1  Congress  at  Madrid,  Section  of  General  Surgery, 
1904,  p.  493. 

DIFFICULTIES  OF  PRISMATIC  CYSTOSCOPY 

Some  of  the  difficulties  that  render  cystoscopy  unsatisfactory  are 
due  to  the  patient  and  others  to  the  instrument. 

Difficulties  Due  to  the  Patient 

1.  Nervousness  of  the  Patient. — Often  the  patient  is  in  such  a  state 
of  fear,  that  he  treml)les  all  over,  thus  making  the  cystoscopic  exam- 
ination extremely  difficult  or  impossible.  It  is  well  to  gain  his  con- 
fidence by  exi)laining  what  is  to  be  done  for  him  and  by  showing  how 
useful  the  examination  is  going  to  be.  It  seems  of  small  consequence, 
but  it  is  very  important  not  to  light  the  lamp  in  the  sight  of  the  pa- 
tient; for  he  is  apt  to  believe  that  the  lamp  is  going  to  burn  him  or 
])urst  inside  of  his  bladder,  thus  adding  considerably  to  his  fears. 

2.  Inflammation  of  the  Urethral  Mucosa. — The  urethra  may  be  in- 
Hamed  and  iiresent  a  more  or  less  acute  discharge.  When  the  inflam- 
matory lesions  are  recent,  cj^stoscopy  must  be  postponed  so  as  not  to 
increase  the  existing  inflammation. 

3.  Atresia  of  the  Urethral  Meatus. — In  this  condition  there  are  two 
courses  to  pui-suo:  If  the  meatus  is  so  narrow  that  it  admits  no  instru- 
ment greater  in  caliber  than  No.  15  Charriere,  meatotomy  must  be  per- 
formed; or,  as  is  more  frequently  the  case,  the  meatus  may  be  some- 
what larger  and  will  admit  a  No.  18  sound,  but  the  introduction  of  the 
cystoscope  causes  considerable  pain.  In  the  latter  circumstance,  insert 
a  little  taiii])()n  of  cotton  satuiated  with  a  few  drops  of  10  per  cent 
stovaine  solution  into  the  meatus  and  the  fossa  navicularis:  dilate  with 


190  CYSTOSCOPY   AND    URETHROSCOPY 

a  metal  dilator,  similar  to  the  one  devised  by  Howard  Kelly,  and  by 
gentle  stretching,  the  cystoscope  may  be  gently  introduced. 

4.  Spasm  of  the  Bulbomembranous  Urethra. — In  nervous  patients, 
•we  frequently  meet  with  a  reflex  spasm  of  tlie  membranous  sphincter 

which  may  Be  violent  enough  to  completely  prevent  the  introduction  of 
the  cystoscope.  This  may  be  overcome  by  lowering  the  head  of  the  pa- 
tient to  the  horizontal  plane,  bending  the  thighs  on  the  pelvis,  and  hav- 
ing the  patient  breathe  deej)ly  and  slowly.  Finally,  if  these  measures 
do  not  succeed,  relaxation  may  be  accomplished  by  injecting  10  c.c.  of 
a  1  per  cent  stovaine  solution  into  the  anterior  urethra. 

[The  editor  usually  overcomes  this  spasm  by  introducing  a  few 
alypin  tablets  into  the  deep  urethra  by  means  of  Bransford  Lewis' 
tablet  depositor;  this  not  only  breaks  up  the  spasm,  but  at  the  same 
time  produces  an  excellent  anesthesia  of  the  deep  urethra,  and  thereby 
facilitates  the  examination  considerably. — Editor.] 

5.  Urethral  Stricture. — (3ccasionally  a  stricture  of  the  urethra  pre- 
vents the  introduction  of  the  cystoscope.  In  these  cases,  the  urethra 
must  be  dilated  until  its  caliber  is  sufficient  to  admit  the  passage  of  the 
instrument  comfortably. 

In  tuberculosis  of  the  kidneys  or  of  the  prostate  associated  with 
cystitis,  the  posterior  urethra  and  the  membranous  portion  are  often 
the  seat  of  an  inflammatory  tuberculous  process  which  causes  altera- 
tions of  the  mucosa,  thus  preventing  the  comfortable  introduction  of 
the  cystoscope.  V\^hen  the  instrument  reaches  these  parts  bleeding  en- 
sues, which  not  only  increases  the  pain  but  likewise  obscures  the  prism 
and  makes  vision  extremely  difficult  or  altogether  impossible.  In  such 
instances,  slow  and  methodic  dilatation  should  be  instituted  and  the 
greatest  gentleness  should  be  exerted  when  the  cystoscope  is  subse- 
quently introduced. 

6.  Prostatic  Hypertrophy. — In  this  condition,  the  canal  is  de- 
formed and  the  cystoscope  is  forced  to  open  a  way  for  itself  across  the 
displaced  prostatic  lobes  which  are  hypertrophied  and  usually  con- 
gested. Here  again,  it  is  absolutely  necessary  to  proceed  with  the  ut- 
most gentleness  possible,  so  as  to  avoid  trauma  and  hemorrhage. 

7.  Diminished  Bladder  Capacity. — Occasionally  the  bladder  has 
not  the  iDroiDer  caj^acity  for  its  imfolded  walls  to  be  sufficiently  distant 
from  the  prism  of  the  cystoscope.  For  good  cystoscopy,  it  has  been 
determined  there  should  be  200  c.c.  of  fluid  in  the  bladder.  Even  with 
but  80  c.c.  cystoscopy  can  be  performed,  but  when  the  capacity  falls 
below  60  c.c,  the  difficulties  assume  such  grave  proportions  that  any 
attempt  at  c^^stoscopy  must  be  abandoned.  In  these  cases,  the  under- 
lying C3^stitis  must  be  treated  first,  by  irrigations  or  injections,  and  the 


DIKFIcri/riKS    Ol'     I'IMS.MATIC    C\ST()M'()P\  191 

('yslosc'()i)i('    t'xaiiiiiialioii    j)()si|)()ii(M|    to    a    siiltsciiiicnl    tiiiK!    when   lliu 
hladdoT"  miioosa  lias  l)(H'()mo  suniciciilly  caliiKMl. 

S.  Contraction  of  the  Bladder.  l^'r'Mniciilly,  ilic  palicnl  siiddcnl) 
l)(',i;ii!s  lo  colli  raci  llic  hladdci'  iii\'()luiilai'il  y  dui'iii<i,'  cystoscopy;  juii-- 
ticularlx'  is  this  true  in  nervous  women.  Tlic  cxainiiialion  is  11ins  I'cn- 
dcrcd  ini])()ssil)lc.  ^'lic  iiisl  i-unicnt  should  Ix'  taken  out  (jiiickly  and  tlie 
examination  deFen-ed  to  a  late)'  sittin.i;'. 

{).  Opacity  of  the  Vesical  Medium. — Tlie  vesical  fluid  may  l)e 
made  tui-1)id  by  tlie  presence  ol"  pus  or  blood.  This  occurs  in  liema- 
luria  or  ])rofuse  renal  pyuria,  in  whicb  two  or  tlii'ee  nroteral  omissions 
suffice  to  completely  obscure  the  fluid  in  the  bladder.  In  these  cir- 
cumstances the  experienced  cystoscopist  employs  his  entire  skill  so  as 
to  be  able  to  look  ([uickly  and  to  make  his  diai^nosis  as  to  the  cause  of 
I  lie  ti()u))le  during  an  unexpectedly  good  momentary  view.  In  other 
circumstances,  tlie  operator  will  be  obliged  to  use  the  irrigating 
cystoscope. 

Difficulties  Due  to  the  Instrument 

1.  Failure  of  Illumination  in  the  Lamp. — This  is  an  extremely  dis- 
agreeable occurrence.  One  sliould  always  have  several  reserve  lamps 
at  hand  in  order  to  make  a  change  when  necessary;  it  is  better  still  to 
have  other  cystoscopes  on  hand,  sterilized  and  ready  for  service,  as  a 
precaution  against  sepsis  in  changing  the  lamps. 

AVhen  illumination  fails,  the  fault  is  not  always  in  the  lamp  neces- 
sarily; the  other  points  of  contact  must  be  examined  carefully,  espe- 
cially at  the  handle  and  at  the  rotating  contact  and  interrupter.  It  is 
well  to  remember  that  only  a  very  slight  failure  of  contact  is  sufficient 
to  interfere  with  the  required  illumination. 

The  electric  contact,  as  is  well  knoAni,  is  made  by  a  metallic 
"spiral,"  the  elasticity  of  which  assures  the  continuity  of  current  be- 
tween the  bod}^  of  the  cystoscope  and  the  filaments  of  the  lamp.  AVhen 
the  lani])  does  not  give  a  proper  light,  it  is  often  sufficient  to  stretch 
or  lengthen  this  little  spiral  with  a  pair  of  foi-ceps  and  this  will  restore 
the  ])assage  of  the  current  in  the  lamp. 

2.  Obscured  Vision. — Cloudiness  of  the  ])icture  during  cystoscopy 
ma\'  be  due  to  difTerent  causes.  The  ])rincipal  and  most  frequent  is 
the  result  of  faulty  introduction  of  the  cystoscope.  When  tiie  opei'ator 
is  not  skillecl,  he  is  a})t  to  introduce  the  cystoscoije  not  far  enough  into 
the  Idachler.  In  these  circumstances,  he  liuds  himself  ])luiig(Ml  in  dark- 
ness and  sees  ahsolutelN'  nothing.  To  ohtain  a  clear  \"ie\v  the  cystosco])e 
should  be  pushed  a  little  further  into  the  liladder  cavity  so  as  to  get 
I'm'  of  the  prostate  and  hiadder  neck. 


192 


CYSTOSCOPY    AiSTD    URETHROSCOPY 


The  reverse  may  also  occur.  AYheii  the  cystoscoiDe  has  been  in- 
serted too  far  into  the  bladder,  it  is  surrounded  with  vesical  mucosa  as 
in  a  hood  (Fig.  131),  with  the  result  that  nothing  can  be  seen.  *lBy  with- 
dramng  the  instrument  a  little,  thus  freeing  the  beak,  the  \T.ew  be- 
comes clear  again. 

3.  Spots  in  the  Visual  Field. — Tliis  is  unfortunately  a  rather  fre- 
quent occurrence,  met  with  especially  when  the  instrmnents  have  beeu- 
used  for  some  time.  When  the  spots  are  found  on  the  ocular  or  on  the 
prism,  it  is  easy  enough  to  remedy  this  condition,  but  at  times  the 
damage  is  more  serious  and  the  instrument  must  be  repaired  at  the 
factory.  These  spots  on  the  optical  apparatus  were  cpiite  frec|uent 
when  the  instruments  were  sterilized  in  triox\'metliylene  (paraform) 
vapor.    A^^ien  prismatic  cystoscopes  are  permitted  to  remain  in  con- 


Fig.   131. — Faulty  introduction  of  the  cystoscope,  which  is  covered  by  the  mucosa  as  with  a  hood. 


tact  with  this  vapor  for  some  time,  the  held  of  vision  usually  ])ecomes 
clouded;  for  this  reason,  I  recommended  long  ago,  a  specual  ai3i)aratus 
for  sterilization  of  prismatic  cystoscopes  (Fig.  124). 

4.  Opacity  of  the  Vesical  Medium. — The  difficulties  which  are  the 
result  of  marked  hematuria  or  pyuria,  and  which  make  the  vesical 
medium  opaque,  will  usually  be  avoided  by  the  employment  of  the 
irrigating  cystoscope. 

5.  Opacity  of  the  Window  of  the  Prism. — Unfortunately  even 
Avhen  the  cystoscope  has  been  introduced  into  the  bladder  correctly,  the 
operator  often  tinds  it  impossible  to  get  a  clear  image,  because  in 
passing  through  the  urethra  the  jDrism  has  been  soiled  with  blood. 
This  is  encountered  quite  frequently  in  connection  with  hypertrophy  of 


CYSTOSCOPY  IN  CHILDREN  193 

llic  prostate,  wliii-li  hlccds  easily  and  thus  soils  llic  prism,     TIk;  irri- 
gating prism  is  extremely  useful  in  these  cases. 

Finally,  other  complications  may  rise  from  the  optical  apparatus, 
— the  lenses  may  get  out  of  order  or  the  diaphragm  may  encroach  upon 
the  visual  field.  All  these  conditions  are  due  to  the  wear  and  tear  of 
the  iust  luiiieiits  and  require  attention  at  the  hands  of  the  manufac- 
turer. 

CYSTOSCOPY  IN  THE   FEMALE 

In  the  female,  cystoscopy  is  much  siinj)ler  than  in  the  male,  because 
the  female  urethra  is  shorter.  The  cystoscope  is  generally  introduced 
without  any  difficulty;  hut  cases  occur,  however,  in  which  the  meatus 
is  narrowed  by  stricture,  and  this  must  he  dilated.  Local  anesthesia 
may  he  produced  h}^  inserting  in  the  urethra  a  pledget  of  cotton  satu- 
rated, with  several  drops  of  a  10  per  cent  solution  of  stovaine.  [A  2  per 
cent  solution  of  alypin  or  novocaine  is  highly  satisfactory-  for  this  pur- 
pose, without  the  risk  attending  the  use  of  stovaine. — Editor.] 

Dilatation  of  the  urethral  meatus  should  he  carried  out  AA'ith  ex- 
treme gentleness,  for  a  considerable  amount  of  dilatation  is  not  essen- 
tial. Furthermore,  since  this  is  usually  followed  by  slight  bleeding, 
gentleness  is  required  so  that  the  prism  of  the  cystoscope  shall  not  be 
blood  stained  in  passing  through  the  urethra. 

CYSTOSCOPY  IN  CHILDREN 

Because  of  the  small  caliber  of  the  urethra  in  the  child,  it  is  neces- 
sary^ to  use  specially  constructed  cystoscopes  particularly  in  boys.  In- 
struments have  been  made  exceedingly  small,  with  a  caliber  correspond- 
ing to  No.  15  Charriere;  and  '^^ith  these  instruments  it  is  possible  to 
make  a  fairly  satisfactory  examination  in  children. 

In  girls,  the  urethra  being  short  and  much  more  easily  dilated  than 
in  boys,  the  use  of  cystoscopes  of  reduced  caliber  will  not  be  nearly  so 
frequently  required;  in  boys,  however,  it  is  sometimes  impossible  to 
get  along  without  these  special  models.  It  goes  without  saying,  that  the 
visual  field  in  these  instruments  is  necessarily  limited.  Besides,  they 
are  fragile  and  much  more  delicate  than  the  ordinary  cystoscopes. 

CARE  OF  THE  CYSTOSCOPE 

The  indirect  A'Ision  cystoscope  requires  a  great  deal  ol*  care  and 
should  be  kept  perfectly  clean.  It  slioidd  be  protected  against  jan-ing 
and  against  dust  and  danqmess.  Xothing  is  more  uiqileasant  than  find- 
ing one's  instrument  unfit  for  use  when  it  is  needed. 


194 


CYSTOSCOPY   AND   UEETHEOSCOPY 


As  regards  the  catheterizing  cystoscope,  the  ureteral  attachment 
is  washed  freely  with  water  immediately  after  use ;  it  is  well  to  cleanse 
the  entire  instrmnent  thoronghty  with  soap  snds.  The  nreterahportion 
and  the  rubber  cap  should  be  boiled  in  water  and  the  rest  of  the  instru- 
ment cleaned  inside  and  out  with  oxycyanide  of  mercury  solution  or 
alcohol ;  but  the  latter  should  not  be  permitted  to  remain  on  the  prism 
for  it  might  loosen  it.  The  cystoscope  and  all  its  accessories  are  then 
thoroughly  dried,  the  ocular  well  corked  and  put  away  in  a  dry  place. 

ADVANTAGES  OF  INDIRECT  VISION 
(PRISMATIC)  CYSTOSCOPY 

The  prismatic  cystoscoiDe  has  distinct  advantages.  This  marvel- 
ous instrument  offers  a  clean-cut  thorough  examination  of  the  bladder 
combined  with  a  large  visual  field  (Fig.  132).    A  large  area  is  brought 


Fig.    132. — lyarge   visual    Held    of   iS'itze's    cystoscope. 

into  view,  not  a  small  spot,  thus  making  a  general  examination  easily 
possible.  If  a  tumor  is  present,  its  general  relations,  its  surface  and 
sometimes  its  implantation  can  be  plainly  seen. 

A  second  great  advantage  is  that  the  caliber  of  the  instrument  is 
diminished  and  that  it  is  introduced  into  the  bladder  with  comparative 
ease.  The  two  great  advantages  of  this  method  are,  therefore,  the 
reduced  caliber  of  the  instrument  and  the  large  area  of  the  visual 
field,  which  brings  a  considerable  portion  of  the  vesical  mucosa  within 
range  of  the  eye. 


DISADVANTAGES  OF  INDIRECT  VISION  CYSTOSCOPY 

1.  Considerable  Experience  Is  Required. — It  is  impossible  for  a 
novice  to  make  a  successful  examination  the  first  time  he  uses  this 


DISADXAXTACICS    OK    INHIItKCT    VISlOX    CYSTOSCOPY 


.lO.-) 


Iiisl  niiiiciil  :  ill  order  lo  cstiihlisli  n  (lia,!j,-ii()sis  in  accord  willi  llic  data 
|)rcscnl('(|  l)y  Uic  iiisl  rimiciif ,  it  is  ahsoliildy  necessary  1o  he  well  ac- 
cuslonied  lo  <'\sl()scopic  manipulation. 

The  iioxice  must  train  his  oyc  and  iiis  liand;  liis  oyo,  in  oi-dcr  to 
learn  how  lo  looiv  at  tlic  iina,i;-(^  and  to  give;  it  a  correct  interpretation; 

his  hand,  so  as  to  be  able  to  place  the  instrument 

A^^: ^B      jj^  ^  proper  position;  that  is,  neither  too   t'ai- 

<Nv        /  /  i'l'om  nor  too  neai'  the  ol).ject. 

2.  The  Image  Is  Reversed  and  Deformed. — 
Pi'imai'ily  tlie  pi-isin  reverses  tlie  picture,  hut  in 
the  vertical  plane  only.  In  the  transverse  phine, 
on  the  other  hand,  the  image  maintains  its  real 
position.  In  other  words,  the  eye  sees  on  the 
right  side  what  is  really  on  the  right  side,  and 
on  the  left  what  is  actually  on  the  corresponding 
side.  On  the  other  hand,  what  is  actuallj^  in 
front  appears  posteriorly  and  the  posterior  por- 
tions of  the  image  appear  anteriorly. 

In  order  to  understand  the  deformities  caused  by  the  cystoscopic 
l)rism,  the  laws  of  reflection  in  plane  mirrors  should  be  borne  in  mind. 


I'ig.  133. — Schematic  repre- 
sentation of  the  reflection  of  an 
image  in  a  plane  mirror  (Nitze). 


I"ig.    134. — Schematic    representation    of    Nitze's    system. 


Fig.    135. — Schematic   representation    of 
Xitze's    system. 


It  is  well  known  that  tlie  image  of  an  object  ])laced  in  front  of  a  i^lane 
mirror  is  seen  at  a  point  equidistant  beliind  the  mirror;  the  image  is 
syniiiieti-ical  with  the  oliject.  The  arrow  Af>  (Fig.  1,",;^)'  which  is  re- 
II<'<-1ed  by  the  mirror  il/xV  is  in  realit\-  seen  in  the  points  A'I>". 

in  Figs.  ];J4,  i;];"),  i:^(i,  and  i:'?,'  it  inav  he  seen  how   the  imaii'es  of 


196 


CYSTOSCOPY   AND    UEETHEOSCOPY 


the  bladder  are  really  perceived,  according  to  the  different  ways  in 
which  the  cystoscope  is  held.  The  lines  ab  represent  the  prolongation 
of  the  cystoscopic  mirror;  the  arrow  AB  represents  the  object,  and 
the  arrow  A'B'  represents  the  real  position  of  the  image.  It  is  thus 
understood  hoAV  the  images  seen  through  the  cystoscope  may  be  de- 


R/ 


Fig.   136. — Schematic   representation    of   Nitze's   system. 

formed  and  different  from  the  reality.     Even  though  the  operator 
succeeds  in  understanding  these  inversions  and  in  correctly  interpret- 


Fig.    137. — Schematic   representation   of   Nitze's   system. 

ing  them,  the  eye  must,  nevertheless,  become  accustomed  to  them  only 
after  considerable  practice. 

The  determination  of  the  real  size  of  the  object  is  likewise  affected 
by  the  deformity  caused  by  the  prism.    According  to  the  position  of 


DlSADVANTAdE.S    OF    INIMKl'XT    VISIOX    CYSTOSCOPY  197 

the  prism,  more  or  less  close;  to  tlic  ohjccl  in  tlic  hladdo",  an  image 
corrospoii(liii,i;ly  largo  will  ])o  obtaiiKMl.  Considerable  experience  is, 
I  lierel'oi-e,  i'e(|uir(Ml  to  delcniiiiie  wliai  size  to  allrihule  to  a  liiiiioi'  ol' 
ilie  hiaddei',  for  exami)le.  Frank's  cystoscoije  lias  obviat(Hl  tlie  lirst 
object  ion  l)y  allowing-  the  object  to  be  seen  by  corrected  vision;  never- 
theless, it  has  not  i-emedied  the  second  objection,  for  the  portions 
nearest  the  2:)rism  aic  considerably  enlarged  while  those  laitliest  oCC 
are  nmch  smaller.  [All  American  cystoscopes  are  now  constructed  so 
as  to  eliminate  the  reversed  image. — Editor.] 

3.  A  Tolerant  Bladder  Is  Required. — To  ol)tain  a  good  view,  it  is 
essential  that  the  vesical  walls  be  sufficiently  separated  from  one  an- 
other ;  otherwise  a  dim  and  hazy  view  is  obtained.  Very  often  the 
bladder  contracts  very  painfully  in  spite  of  the  use  of  a  local  anes- 
thetic such  as  stovaine,  and  this  renders  the  examination  impossible 
notwithstanding  all  our  efforts.  The  examination  must  then  be 
abandoned. 

[General  anesthesia  may  be  resorted  to  in  these  cases  with  satis- 
factory results.^ — Edttor.] 

4.  A  Transparent  Medium  Is  Required.— The  fluid  medium  in  the 
bladder  should  remain  transparent  throughout  the  examination.  This 
essential  condition  is  extremely  difficult  to  attain,  at  times,  Avhen  we 
are  dealing  with  a  severe  cystitis,  profuse  renal  p3^uria,  or  hematuria 
of  prostatic,  vesical,  or  renal  origin.  It  is  but  proper  to  add  that 
these  disadvantages  are  overcome  by  the  use  of  copious  irrigation; 
but  there  are  cases  in  which  the  obstacles  are  absolutely  insurmount- 
able and  the  examination  must  be  abandoned. 

Attempts  have  been  made  to  avoid  this  difficulty  by  filling  the 
bladder  with  air  under  pressure,  instead  of  water;  this  constitutes  a 
medium  which  remains  transparent  constantly,  but  the  view  of  the 
vesical  walls  is  defective  Avhen  seen  under  these  conditions.  Xitze  has 
advised  against  this  method,  insisting  particularly  on  the  fact  that  the 
vesical  walls  appear  as  though  they  were  covered  witli  brilliant  vainisli, 
thus  making  the  examination  difficult. 

It  is  impossible  to  obtain  a  clear  view  if  the  prism  is  too  near 
the  object  to  be  examined;  the  instrument  should  be  held  at  the  proper 
distance.  When  this  can  not  be  done  because  of  certain  deformities 
of  tlie  bladder,  vision  through  the  cystoscope  becomes  extremely  diffi- 
cult.    This  is  frequently  met  witli  in  pregnancy. 

EEFERENCE 

iNitzc:     LcliiLucli  cler  Kystoscopio,  Wiesbaden,  Bergman,  1007,  pp.  12G,  127. 


198  CYSTOSCOPY    AND    UEETHROSCOPY 

THE  NORMAL  BLADDER  AS  SEEN  THROUGH  THE  INDIRECT 
VISION  (PRISMATIC)  CYSTOSCOPE 

A^^len  the  cystoscope  lias  been  introduced  into  the  bladder  and 
the  prism  is  turned  toward  the  roof,  a  bubble  of  air  is  seen,  which 
indicates  the  summit  of  the  bladder.  Anteriorly,  is  a  rather  i^oorly 
illuminated  depression.  This  represents  the  projection  of  the  bladder 
above  the  pubis,  and  in  the  female  constitutes  the  suprajoubic  recess. 
Scattered  throughout  the  vesical  wall  are  blood  vessels  which  radiate 
like  stars. 

When  the  prism  is  turned  do^wmward,  the  line  of  the  interureteral 
ligament  or  muscle  is  plainly  seen;  this  stands  out  clearly  and  promi- 
nently as  a  thin,  well-illuminated  band. 

Behind  this  line  is  a  depression,  which  corresponds  to  the  bladder 
fundus.    Anteriorly,  the  trigone  is  seen,  always  more  vascular. 

Turning  the  prism  laterally,  the  side  walls  of  the  bladder  come  into 
view.  In  the  female,  because  of  the  uterus,  they  appear  dex^ressed  and 
constitute  the  so-called  horns  of  the  bladder. 

The  neck  of  the  bladder  deserves  special  attention.  When  the 
prism  is  turned  superiorly  the  neck  appears  in  the  form  of  a  crescent, 
Avith  the  convexity  above,  dark  red  in  color;  this  tint  being  somewhat 
less  illuminated,  can  always  be  differentiated  from  the  ]3aler  color  of 
the  rest  of  the  bladder.  Turning  the  cystoscoioe  laterally,  the  bladder 
neck  resembles  a  crescent  shaped  like  the  last  quarter  moon,  the  points 
of  which  are  always  less  clearly  defined.  Finally,  when  the  prism  is 
turned  downward,  we  find  the  lower  part  of  the  neck  not  so  sharply 
outlined,  with  the  result  that  the  margin  of  the  neck  can  not  be  so 
well  differentiated.  At  this  i^oint  the  neck  does  not  project,  but  seems 
to  be  continuous  Avitli  the  posterior  urethra. 

Locating  the  orifices  of  the  ureters  is  generally  cpiite  simple  and 
easy.  For  this  purpose  the  circumference  of  the  ocular  may  be  likened 
to  the  dial  of  a  clock.  Taking  the  little  indicator  button  attached  to 
the  ocular  as  a  guide,  the  beak  of  the  cystoscope  is  placed  to  correspond 
to  six  o'clock  on  the  dial;  that  is,  turned  entirely  doAvnw^ard  and  on 
the  median  line.  Having  found  the  bladder  neck,  the  instrument  is 
pushed  backward  about  2^/2  centimeters;  the  instrument  is  then  turned 
on  its  axis  so  that  the  indicator  button  corresponds  to  eight  o'clock 
on  the  dial  for  the  right  side,  and  to  four  o'clock  for  the  left  side.  Now 
we  have  the  corresponding  ureteral  orifice. 

To  examine  the  entire  cavity  of  the  bladder  systematically,  a  cer- 
tain series  of  movements  should  be  executed  by  the  instrument:  1.  An- 
teroposterior movements  which  bring  the  beak  from  the  bladder  neck  to 


NOItMAI.    IJI.ADDKi;    SKi:x    'I'!  I  IK)  I  i;  1 1    CYSTOSCOPE  ID!) 

the  |)(»s1ci-i()i-  l)la(l(l('r  wall.  2.  Rotai-\  ihonciiichIs  ;n-()iiii<l  the  axi.s,  the 
latlcr  i-ciiiaiiiiii,i^-  slat ioiiarx-.  3.  Seesaw  iiiovciiiciits,  hy  lowering  and 
clcvatiiii;-  llic  ocular.  'V\\i-  latter  inoNciiiciits  ai'e  made  I'roni  above 
downward  or  laterally  Trom  side  to  side.  These  movements  are  pei-- 
haj)s  the  Jiiost  important  in  ol)tainin<>-  detailed  eystoseo])ie  ima.u'es.  l>y 
noting  the  di  (Tci-'Mit  images  obtained  as  a  result  of  these  movements 
of  the  cystoscope,  a  clear  impression  of  the  real  size  and  location  of 
the  object  is  attained. 

Nitze  lias  described  briell\'  liow  the  different  ])ai-ts  of  the  hhid(h'r 
may  ])e  examined  systematically  and  methodically,  as  foHows : 

1.  The  beak  of  the  instrument  having  been  introdncfnl  into  the 
hladder,  it  is  pushed  backward  till  it  comes  into  contact  with  the  por^- 
terior  bladder  Avail. 

2.  The  beak  is  now  turned  from  the  median  line  to  the  right  at 
an  angle  of  45  degrees;  the  instrument  is  now  l)rought  forward  toward 
the  neck  of  the  bladder. 

3.  Having  reached  the  neck,  tlie  beak  is  turned  45  degrees  to  the 
left;  an  effort  being  made  to  hug  the  left  vesical  wall  as  closely  as 
possible,  the  instrument  is  again  pushed  backward  to  the  posterior 
wall. 

4.  Finally,  the  beak  is  again  turned  dowuAvard,  and  the  ocular 
depressed;  this  movement  permits  the  examination  of  the  most  im- 
portant portion  of  the  bladder,  namely,  the  fundus  and  the  trigone. 
By  making  these  movements  methodically,  the  entire  vesical  mucosa 
can  be  examined,  so  that  only  the  minutest  portions  can  escape 
observation. 


THE  PATHOLOGIC  BLADDER  AS  VIEWED  THROUGH  THE 
INDIRECT  VISION  (PRISMATIC)   CYSTOSCOPE 

Cystoscopy  in  Cystitis 

Acute  Cystitis. — Cystoscopy  should  not  l)e  done  in  acute  cystitis 
except  in  very  exceptional  circumstances,  for  this  examination  is  apt 
to  be  more  injurious  than  useful  to  the  patient.  In  tliis  acute  condi- 
tion, the  vesical  jnucosa  may  be  desquamated  and  ulcerated;  the 
slightest  contact  of  an  instrument  with  the  inflamed  nmcosa  is  sufficient 
to  provoke  a  more  or  less  severe  hemorrhage.  Severe  pain  accom- 
panied by  a  mai'ked  febrile  reaction  nia>'  also  result.  In  these  cir- 
cumstances, the  examination  must  l)e  i)()stp()ned  until  the  pain  and 
fever  have  subsided  through  appropriate  treatment. 

The  inflamed  nmcosa  is  generallv  of  a  diffuse  i-ed  color,  and  turiiid 


200  CYSTOSCOPY   AISTD    UKETHROSCOPY 

like  velvet;  this  condition  being  due  to  the  loss  of  epithelium.  The 
entire  structure  and  consistency  of  the  mucosa  are  altered.  In  this 
connection,  Zuckerkandl,  of  Vienna,  has  shown  that  the  bulb*"  of  an 
olivary  bougie  can  be  buried  in  the  substance  of  the  turgid  vesical 
lining  without  injuring  the  mucosa.  Invariably  the  inflammation  takes 
place  at  the  fundus  of  the  bladder  and  is  always  more  marked  at  this 
point.  The  pathologic  alteration  is  in  direct  proportion  to  the  inten- 
sity of  the  inflammatory  process.  The  coloration  varies  from  a  very 
faint  redness  to  a  very  dark  blue,  like  lees  of  Avine,  with  all  the  inter- 
mediary shades.  Even  a  beginner  finds  it  easy  to  diagnose  the  presence 
of  an  inflanmiatory  condition  of  the  vesical  mucosa,  the  inflammatory 
color  of  which  contrasts  strikingly  with  the  smooth  and  brilliant  yellow 
surface  of  the  healthy  mucosa. 

In  acute  cystitis,  the  blood  vessels  can  not  any  longer  be  recog- 
nized ;  the  inflamed  patches  may  be  circumscribed  or  extensive.  They 
manifest  themselves  either  under  the  form  of  small  plaques  or  of 
little  round  patches  like  small  islands.  In  the  early  stages  of  cystitis 
the  mucosa  often  has  the  appearance  of  a  geographical  map.  The 
bladder  is  invariably  dark  red  and  the  normal  mucosa  can  not  be  dis- 
tinguished. At  the  same  time,  there  is  a  swelling  of  the  mucosa  which 
frequently  becomes  edematous,  the  mucosa  then  seems  to  form  little 
hills  and  valleys,  and  sometimes  the  inflammation  is  so  great  that  it 
takes  on  a  varicose  or  polypoid  api^earance.  The  epithelium  of  the 
inflamed  membrane  soon  exfoliates  and  this  is  followed  hj  ulceration 
and  destruction  of  the  mucosa.  Simultaneously  there  is  also  produced 
a  fibrinous  exudate  with  considerable  pus  which  floats  about  in  the 
bladder  fluid.  The  lighter  purulent  flakes  float  on  top  of  the  vesical 
medium;  the  heavier  masses  fall  to  the  bottom  of  the  bladder  where 
they  accumulate.  This  accumulation  of  debris  may  very  often  com- 
pletely prevent  the  cystoscopic  examination,  and  it  becomes  necessary 
to  change  the  fluid  repeatedly  or  to  employ  the  irrigating  cystoscope. 

2.  Chronic  Cystitis. — As  compared  with  acute  cystitis,  the  princi- 
pal feature  characteristic  of  chronic  cystitis  is  that  the  inflammatory 
lesions,  instead  of  being  spread  over  the  entire  bladder  and  covering 
the  mucosa  uniformly,  are,  to  the  contrary,  considerably  circumscribed. 

As  previousl}^  mentioned,  the  most  important  lesions  are  found 
usually  at  the  fundus.  A  considerable  difference  can  be  noticed  be- 
tween a  fundus  which  shows  important  lesions  and  the  apex,  which  has 
the  appearance  of  a  perfectly  healtliy  mucous  membrane.  The  vesical 
mucosa  may  be  red,  the  coloration  being  in  direct  proportion  to  the 
capillary  engorgement.  The  arterial  vessels  considerably  dilated  and 
increased  both  in  size  and  number,  are  tortuous  and  fade  gradually 


rATIlOLOCIC    IlLAIiDKIl    SEEN    TIIItOlIGIE    CYSTOSCOPE  201. 

into  the  redder  paiclies.  Lillk;  red  stains  ai'e  ohseixcd  upon  Ukj  ves- 
sels, wliieli,  hy  iiiiititi.i;-,  increase  tlio  exleiil  oT  llie  iiiilaiiiniatoiy  plaques. 

Cli ionic  cNslitis  is  characterized  usually  by  tlio  presence  in  the 
fundus  ol'  liltle  niuslii'ooui-shapod  G,'rowths  of  a  reddish  color,  auiou^' 
Avhich  exudini;'  masses  are  found.  At  limes  these  excrescences  take  on 
rather  considerable  growth,  even  to  the  extent  of  resembling  a  real 
})apilhmia. 

Often,  the  mucosa  is  joale  and  anemic.  This  is  due,  according  to 
Nitze,  to  the  disappearance  of  the  supeificial  vessels  of  the  nuicosa, 
probably  as  the  result  of  the  thickening  of  the  epithelium  A\liicli  covers 
the  blood  vessels.  "When  the  cajjillary  vessels  reappear  under  the  in- 
fluence of  proper  treatment,  a  cure  may  be  expected. 

The  nmcosa  may  also  take  on  the  appearance  of  a  mosaic  (Plate 
XV,  Fig.  2) ;  the  base  is  of  a  rose  yellow  color  and  the  design  of  the 
mosaic  is  formed  by  the  engorged  vessels.  In  other  instances,  as  Xitze 
has  Avell  demonstrated,  the  vesical  mucosa  resembles  leather,  with 
prominences  which  resemble  heaps  of  wheat  grains  or  lentils.  iVt  other 
times,  the  mucous  tumefaction  may  assume  marked  proportions;  i^ro- 
jections  in  the  form  of  sausages  (Nitze)  may  be  seen  prominently 
throughout  the  bladder  upon  the  hyperemic  mucosa.  These  projec- 
tions are  not  to  be  confounded  with  the  bladder  trabeculations;  some- 
times they  assume  the  form  of  a  cockspur  and  are  usually  separated 
from  one  another  by  dee^D  depressions. 

In  more  severe  cases  the  bladder  is  covered  by  a  great  number  of 
villosities  which  give  it  the  appearance  of  a  lawn;  this  type  is  known 
as  ''villous  cystitis."  The  cystoscopic  picture  is  indeed  striking  in 
these  cases,  for  these  graceful  villosities  take  on  the  same  movements 
as  are  observed  in  a  Avheat  field  moved  to  and  fro  by  the  wind  (Xitze). 

Under  the  designation  of  "parenchymatous  cystitis,"  Nitze  de- 
scribes a  pathologic  condition  of  the  vesical  mucosa  in  which  the  entire 
wall  of  the  bladder  is  completely  changed  by  the  intense  inflammations, 
or  those  of  long  duration;  in  this  condition  because  of  the  presence  of 
scar  tissue,  the  vesical  wall  can  no  longer  distend  itself  without  pro- 
ducing pain.  In  these  cases  some  portions  of  the  nuicosa  are  found  in 
a  highly  inflamed  condition,  glossy,  bright  red,  well  circumscribed  and 
without  any  special  shape,  surrounded  by  mucous  membrane  which  is 
noi-mal,  or  l)ut  slightly  inflamed.  The  affected  part  seems  very  smooth 
and  glossy,  and  upon  its  surface  are  seen  little  raised  areas  like  grains 
of  sand  which  are  very  red  in  color.  AVhen  such  a  bladder  is  filled  with 
water  and  the  patient  sulfers  very  acute  pain,  the  cystoscope  shows  a 
little  crack  or  tear  in  the  bright  red  glossy  j^ortions  in  which  bleeding 
takes  place.    This  parenchymatous  ty]ie  usually  culminates  in  a  shriv- 


PLATE  XII 

Fig.  1. — Xormal  aspect  of  ihv  neck  of  the  Madder,  when  the  tube  of  the 
direct  vision  cvstoscope  has  been  deej)ly  introduced:  Bolow,  on  the 
first  row,  is  seen  the  red  fundus  of  the  bladder,  behind  the  line  of 
which  is  distinguished  a  very  small  quantity  of  urine  not  yet  evacuated. 
The  rest  of  the  figure  represents  the  posterior  and  superior  walls  of  the 
bladder  less  brightly  colored.  The  vesical  reservoir  is  then  greatly  dis- 
tended because  of  the  reclining  position. 

Fig.  2. — Aspect  of  the  'bladder,  not  well  dilated  by  the  reclining  position. 

Fig.  3. — Pathologic  aspect  of  the  right  ureter  chronicaUij  inflamed,  under 
the  influence  of  too  highly  concentrated  urine.  The  lips  of  the  ure- 
teral orifices  are  edematous  and  swollen  and  the  same  marked  chronic 
inflammation  is  seen  in  the  immediate  region  which  the  urine  must  fol- 
low in  leaving  the  ureteral  orifice. 

Fig.  4. — Aspect  of  plaques  of  simple  chronic  nontuhercidous  cystitis  seen 
with  the  direct  vision  cvstoscope.  These  plaques  are  frequently  observed 
in  chronic  cystitis  and  are  mucli  more  easily  distinguished  with  the 
direct  vision  cystoscope  when  the  tube  is  held  in  profile,  than  when  seen 
in  full  view.  This  was  a  case  of  cystitis  which  had  developed  in  a 
woman  with  simjile  pyonephrosis,  in  which  all  the  bacterial  examina- 
tions and  guinea  pig  inoculations  were  negative. 

Fig.  5. — View  of  a  papillomatous  tumor  of  the  bladder  seen  with  the  direct 
vision  cystoscope. 

Fig.  6. — Normal  vesical  wall  in  contraction.  This  view  can  not  be  observed 
well  except  with  the  direct  vision  cystoscope,  for  in  indirect  pris- 
matic cystoscopy,  the  walls  are  distended  by  the  liquid  and  can  not 
contract  freely.  In  the  lower  pait  of  the  figure,  the  interureteral  mu- 
cosa is  seen;  in  the  upj)er  part  during  a  vesical  contraction,  the  blad- 
der comes  close  to  the  extremity  of  the  tube,  and  assumes  the  ap- 
pearance of  intestinal  convolutions. 


Fis.  1. 


Fig.  2. 


Fig.  3. 


Fig.  4. 


PLATE  XII 


Fig.  6. 


rA'i'iioi.ocic   iii.AiiDi'Mi  S!':i<:x  tii  iiorcii    (  asi'oscopi-:  203 

(;1('.(1  U])  l)lail(l<'i-  mid  is  rr('(jii('ii1 1\-  the  I'csiill  oT  ;i  1  iilx'i'culous  |)1-(K'('S.s. 

Follicular  of  ,i;i-aiiular  cNsiilis  is  (|uil('  coiiiiiioii.  It  appears  in  the 
Toi'iii  of  a  sul)('|)illirliai  iiilill ration  made  uj)  of  lyiiiplial ic  follicles  wliicli 
arc  Jillcd  witli  lymphoid  cells.  Occasionally  these  J'oUielcs  are  sepa- 
rated tVoiii  one  another  hv"  healthy  tissne;  or  tliey  may  he  vei'y  close 
lo,<;-etliei-.  Tliey  sometimes  consist  ol*  numei'ons  little  limpid  N'csicles  as 
larjj:e  as  lentils,  sometimes  smaller  (Plate  Xll,  V'l'^.  4,  and  Plate  XIV, 
Fi<>,-.  1).  Tliey  may  also  he  disseminated  over  tlie  entire  mncosa,  re- 
semhlini;'  dro])s  of  water,  clear  as  crystal.  This  is  the  condition  w  ITudi 
Ortli  lias  desio-nated  under  the  title  of  ''PFerpes  A^sicalis"'  (Plate  XIV, 
Fi^\  "2).  These  vesicles  may  resemhle  caviar,  or  when  larger,  they  may 
simnlate  varioloid  pnstnles  (Nitze).  These  follicles,  the  contents  of 
which  may  he  clear,  cloudy,  or  purulent,  seem  to  have  no  very"  distinct 
signiticance  so  far  as  the  diagnosis  and  prognosis  are  concerned. 

It  was  formerly  helieved  that  this  form  of  gi-anular  c^^stitis  is  en- 
countered in  cases  which  are  tuherculous  in  nature.  Such  is  not  the 
case,  however;  in  many  instances,  this  form  of  cystitis  is  met  with  in 
cases  in  Avhich  there  is  not  the  slightest  suspicion  of  tuherculous 
infection. 

In  the  case  of  a  young  woman  with  an  enormous  nontulierculous 
pyonephrosis  Avitli  chronic  cystitis,  examination  of  the  centrifuged 
urine  and  guinea  pig  inoculations  proved  conclusively  that  tuherculosis 
was  out  of  the  question  (Plate  XII,  Fig.  4).  The  patient  Avas 
nephreetomized,  and  she  recovered  completely.  The  removed  kidney 
presented  no  tuherculous  lesions.  Seen  again  eight  years  later,  her 
hladder  was  in  perfect  condition  and  did  not  show  the  slightest 
trace  of  granular  cystitis.  Tuherculosis  was,  therefore,  completely 
excluded. 

Gonorrheal  cystitis  is  characterized  1)y  the  presence  of  circum- 
scrihed  inflammatory  plaques  in  which  the  hriglit  red  mucosa  is  covered 
with  vessels  gorged  with  hlood.  These  plaques  are  usually  found 
around  the  neck  of  the  hladder  chiefly  on  the  lower  \\a\\.  The  epithe- 
lium is  most  often  exfoliated  and  floats  in  the  vesical  fluid. 

Tuherculous  cy^stitis  often  gives  such  a  characteristic  cystoscopic 
picture  that  the  exact  diagnosis  can  he  made  frequenth^  at  the  fii-^  ex- 
amination hy  the  expert  eye.  It  is  characterized  in  the  early  stages  hy 
the  ])i-esence  ol'  suiall  elevations  in  the  form  of  nodules  the  size  of  a 
pinhead  or  of  a  lentil,  and  of  a  red  or  l)rowii  color.  Facli  of  these 
nodules  is  at  flrst  surrounded  with  a  cii'cle  ol'  veiy  line  blood  vessels; 
thev  soon  hecome  ulcerated,  are  I'ound  or  irregular  in  I'orm,  and  al- 
most entirely  suri'ouiided  l)y  a  vei'v  red  hordei-.  These  ulcerations  fre- 
quently ha\'e  the  a])pearance  ol'  n  liuger  nail  sciatch  or  dent;  they  are 


204  CYSTOSCOPY   AND    URETHROSCOPY 

arcli-sliaped  and  deep,  affecting  the  vesical  mucosa  throughout  its  en- 
tire thickness.  The  base  of  the  ulceration  is  wrinkled  and  dirty  and 
yellowish  in  color.  The  edge  of  the  ulceration  is  elevated  lik^a  ram- 
part, as  if  cut  with  a  saw  (Nitze).  Immediately  surrounding  the  ul- 
ceration the  vesical  mucosa  is  very  red  and  thick;  as  many  as  five  to 
twelve  nodules  and  ulcerations  may  coalesce,  forming  herpetic  groups 
separated  from  one  another  by  a  strip  of  mucosa  which  is  sometimes 
entirely  normal,  at  other  times  faintly  reddish  in  color. 

The  nodules  occasionally  present  themselves  in  the  form  of  a  collar 
or  ring;  at  other  times  they  arrange  themselves  around  a  blood  ves- 
sel producing  the  appearance  of  a  branch  of  bilberry  (Nitze).  AVhen 
the  nodules  or  ulcerations  are  fairly  limited  around  the  ureteral  or- 
ifices, the  opi3osite  orifice  being  completely  normal,  the  diagnosis  of 
renal  tuberculosis  can  be  positively  made  by  a  simple  cvstoscopy  (Plate 
XVI,  Fig.  1). 

Under  the  name  'S^esical  leucoplakia, "  Brick  has  described  a 
cystoscopic  appearance  consisting  of  bright  Avliite  iDlaques  which  are 
elevated  above  an  extremely  red  vesical  mucosa.  These  plaques  are 
very  adherent  to  the  underlying  tissue ;  if  they  are  rubbed  mth  cotton, 
the  deep-seated  mucosa  bleeds.  When  examined  microscopically  it 
can  be  seen  that  they  are  histologically  thickened  epithelium.  A  typ- 
ical vesical  leucoplakia  is  seen  in  Plate  XV,  Fig.  1. 

"Bullous  edema,"  described  by  Kollischer,  is  found  particularly 
in  women.  It  appears  in  the  form  of  clear  vesicles,  the  size  of  a  grain 
of  wheat  or  that  of  a  small  pea;  they  may  also  be  found  much  larger. 
This  condition  is  met  with  in  phlegmasia  of  the  uterus  or  of  its  adnexa, 
especially  in  cancer  of  the  uterus  (Plate  XXI,  Fig.  1,  and  Plate  XXIV, 
Fig.  3) ;  it  is  also  found  in  certain  cases  of  pyosalpinx. 

The  catarrhal  exudate  which  accompanies  cystitis  is  more  or  less 
abundant  according  to  the  severity  of  the  inflammation.  Its  compo- 
sition is  almost  constantly  the  same;  masses  of  exfoliated  vesical  epi- 
thelium, leucocytes  and  red  blood  cells  may  always  be  found  in  it. 
"When  the  urine  undergoes  ammoniacal  fermentation,  the  exudate  be- 
comes more  dense  and  contains  both  amorj)hous  and  crystalline  salts. 
When  purulent  masses  predominate  in  the  catarrhal  exudate,  they  may 
adhere  to  the  surface  of  the  mucosa  and  thus  completely  change  its 
appearance.  When,  however,  they  become  mixed  with  the  vesical  fluid, 
the  latter  becomes  turgid  and  opaque.  In  mild  cases  the  exudate  con- 
sists of  little  masses  of  pus  or  mucus  which  cover  a  considerable  por- 
tion of  the  bladder  mucosa.  These  mucous  masses  are  white  or  grayish 
in  color,  and  often  resemble  snowflakes.  When  gathered  together  at 
the  fundus  they  may  be  mistaken  for  a  vesical  calculus.    In  more  severe 


PATHOLOGIC    BLAIi|)i;i;    SKi;.\     IIHIOUGII    CYSTOSCOPE  205 

cases  tlie  oxudaic  is  seen  in  Ihc  ronn  ol'  a  iiicnilti'aiic  wliicli  Ix'coiiics  (le- 
tac1i((l  fioiii  llie  vesical  wall  IVoni  lime  to  liinc  and  ci-osses  tlie  field  of 
vision  al)riij)lly  like  a  siKcr  lisli  (Xitzc).  Occasionally  false  mem- 
branes are  seen  adlici-cni  lo  Hie  Ncsical  Jiiucosa  by  one  of  llicii-  mar- 
g'ins.  Tlieir  nnat.laclnMl  poitions  float  freely  in  tlie  vesical  lluid  lik(i 
a  cui'laiti  Mow  ii  l»_\'  llic  wind,  oi'  like  a(iuatic  plants  (Nitzc). 

Cystoscopy  in  Bladder  Tumors 

AViien  a  bladder  tumor  is  comjjaratively  small  and  does  not  bleeii, 
llic  image  produced  in  an  indirect  vision  cystoscope  is  often  very  fas- 
cinating. The  splendid  outlines,  the  pinkish,  bright  red  color,  the 
fimbria;  iloating  freely  in  the  fluid  like  seaweeds  or  like  an  octopus,  con- 
stitute a  sjDlendid  jDicture.  At  times,  the  tumor  is  small  and  may  be 
seen  in  its  entirety  in  the  visual  field;  at  otlier  times  it  is  much  larger, 
so  that  the  cystoscope  nmst  be  moved  about  in  order  to  reveal  the  en- 
tire tumor.  It  is  sometimes  difficult  to  determine  whether  the  tumor 
is  pediculated  or  not,  for  the  pedicle  is  frequently  hidden  by  the  mass 
of  the  tumor.  There  are  cases,  however,  in  wliich  a  pedicle  may  be 
assumed  to  be  present  by  virtue  of  the  fact  that  the  tumor  floats  in  the 
vesical  fluid. 

On  the  other  hand,  when  the  tumor  adheres  closely  to  the  vesical 
wall,  and  especially  when  arterial  pulsations  are  visible,  it  is  evident 
that  the  tumor  is  not  pediculated.  In  certain  instances  when  the  tu- 
mor is  very  large,  the  most  prominent  j^ortion  may  escape  observation 
entirely  because  of  the  complete  darkness  of  the  field.  For  example, 
a  tumor  is  found  on  the  right  side  of  the  bladder.  The  operator  be- 
gins by  introducing  the  cystoscope  so  that  the  lens  and  the  lamp  point 
upward ;  the  entire  pale  vesical  mucosa  can  be  seen  perfectly.  As  the 
cystoscope  is  turned  toward  the  right,  the  image  becomes  obscured 
progressively  until  total  darkness  supervenes  and  nothing  can  be  seen. 
However,  as  the  rotation  toward  the  right  continues,  the  lower  part 
of  the  bladder  comes  into  view  with  its  normal  mucosa.  The  dark  area 
evidently  corresponds  with  the  most  prominent  portion  of  the  tumor, 
which,  coming  closely  in  contact  with  the  prism  and  the  lamp,  makes 
distinct  vision  imj^ossible.  It  is,  therefore,  necessary  in  these  cases, 
to  vary  the  position  of  the  instrument  in  order  to  be  able  to  appreciate 
the  exact  volume  of  the  tumor. 

The  differential  diagnosis  between  a  benign  and  a  malignant  tumor 
of  the  bladder  can  often  be  made  by  the  cystoscopic  view  of  the  mass. 
A  benign  liimor  is  characterized  by  the  villi  Axliich  we  have  already 
mentioned, — delicate,  nndii])l(>  and  Iloating  in  the  vesical  fluid.  These 
benign  tumors  are  also  characterized  by  the  fact  that  they  float  about 


206  CYSTOSCOPY    AND    URETHROSCOPY 

in  tlie  bladder,  being  very  light  in  weiglit.  They  often  resemble  cer- 
tain marine  animals,  in  appearance,  such  as  the  anemone.  They  may 
resemble  a  bnnch  of  grass  or  moss;  or  they  may  have  long  and- narrow 
villosities;  at  other  times  they  have  the  form  of  a  leaf,  a  canliflower, 
a  bunch  of  herbs,  or  an  acjuatic  lolant.  When  the  tnmor  is  near  the 
ureteral  orifice,  the  ureteral  ejaculation  sets  them  in  motion  in  the 
bladder  fluid.  At  times,  they  may  present  movements  synchronous 
with  the  pulse;  this  is  an  evidence  of  intense  vascularization.  Their 
color  is  generally  rather  pale,  and  varies  from  clear  pink  to  a  dark 
rose,  with  often  an  intermediary  discoloration  of  red  ecchymotic  spots. 

Malignant  tumors,  on  the  other  hand,  are  usually  part  and  parcel 
of  the  vesical  wall.  They  consist  of  large  massive  infiltrations  in  the 
form  of  hemispherical  nodules  or  of  irregular  sY\"eJlings  projecting  very 
slightly  from  the  surrounding  vesical  wall.  Their  surface  is  smooth 
or  verrucous.  When  villosities  are  present,  they  are  small  and  curved. 
They  appear  hard  and  firm,  like  wood,  often  in  the  shape  of  a  potato; 
they  are  motionless  and  do  not  float.  Their  upper  part  or  summit  is 
often  covered  with  whitish  masses  like  a  snow-covered  mountain.  This 
appearance  is  usually  due  to  necrosis  of  the  superficial  portions  of  the 
tumor.  AVhen  these  malignant  neoplasms  become  ulcerated,  they  take 
on  the  apjoearance  of  a  crater  at  the  bottom  of  which  are  seen  nodular 
granulations. 

The  coloring  of  malignant  tumors  is  also  different  from  that  of 
benign  growths.  Most  of  the  time  the  color  is  much  darker, — usually 
dark  red,  black,  or  violet,  occasionally  resembling  the  lees  of  wine. 
Finally,  malignant  tumors  are  never  pedunculated  and  their  bases  ad- 
here closely  to  the  vesical  mucosa  and  are  continuous  with  it. 

[Aiuerican  urologists  are  prone  to  regard  all  bladder  tumors  either 
as  actually  or  potentially  malignant  in  character.  A  benign  tumor 
of  today  may  be  the  malignant  tumor  of  tomorrow.  Clinically  the 
diagnosis  is  impossible;  biopsy  via  the  ojoerating  cystoscope,  often 
helps  to  clear  up  doubtful  points,  but  even  this  method  is  o]3en  to 
the  objection  that  a  tumor  may  not  show  malignancy  in  some  por- 
tions, while  other  jDortions  may  offer  absolute  proof  of  its  malignant 
character.  Therapeutically  the  diagnosis  may  be  made  tentatively  on 
the  theory  that  benign  tumors  disappear  under  '^fulguration"  and  do 
not  recur,  while  malignant  growths  are  not  affected  by  this  method  of 
treatment.    The  matter  is  still  unsettled. — Editor.] 

Cystoscopy  in  Certain  Anomalies  of  the  Bladder 

1.  Diverticulum. — This  anomaly  is  met  with  especialh^  in  the  fun- 
dus and  near  the  bladder  neck.    The  mucosa  which  covers  the  interior 


rATii()i,(H;ic   i;i..\hiii:i:   si:i-:\*  tii  i;()i'(.ii    cysToscope  207 

of  llicsc  (li\('ii  iciil.T  is  ,i;('ii('r;ill\'  siiioolli  niid  willioiil  folds.  At  liiiics 
llicv  limy  l)('  (|iiil('  l;ii',i;('  and  may  i-csciiiIjIc  sccoiidary  Madilfi's.  Soiiic- 
tiiiies  tlicy  ai'c  lai'.uc  ciiou.^li  lo  pcrinil  llic  inl  rodud  ion  of  the  cysto- 
scope. 

2.  Varices. — Avarices  liavc  hccn  observed  hy  \^ieitel  and  Zncker- 
kandl,  especially  in  ])]'e,i;iian('y.  I  liaxc  ))eeii  ahle  to  soe  tlieni  oi'teii  in 
])reonaiicy,  in  tlie  sei'vice  of  J>ar.  Tliey  iiuiy  ])0  seen  in  men,  and  in 
women  inde])endently  of  ijreftnancy,  hut  ([uite  excejjtionally.  Tlioy 
may  cause  iiemorrliage  ((iuyon,  LeFiir,  Baraduc)  grave  enongli  to  ne- 
cessitate suprapubic  cystotomy.  In  prostatic  liypertropby,  dilated  ves- 
sels may  be  seen  near  tlie  base  of  the  i:)rostate.  Viertel  lias  observed 
premenstrual  hematuria.  In  these  cases  it  is  the  parenchyma  of  the 
mucosa  Avhicli  bleeds  and  it  is  only  very  rarely  that  tlie  blood  may  be 
seen  issuin,^'  fi'oni  a  blood  vessel. 

Cystoscopy  in  Cancer  of  the  Uterus 

The  observations  on  the  importance  of  cystoscopy  in  uterine  can- 
cer^ which  I  ])ublished  some  years  ago,  have  been  confirmed  by  Cruet" 
and  l)y  Violet  and  Murard.""  Bladder  c^^stoscopy  is  absolutely  neces- 
sary in  uterine  cancer,  for  the  cystoscope  determines  the  indications 
for  or  against  liysterectomy.  Indeed,  nothing  hut  cystoscopy  can  tell 
us  Avhether  or  not  the  bladder  is  involved  in  the  cancerous  process; 
moreover,  if  the  ureteral  orifices  or  the  ureters  themselves  are  seen  to 
be  compressed  by  the  uterine  cancer,  it  will  indicate  that  the  urinary 
function  has  been  seriously  compromised,  thus  constituting  a  distinct 
contraindication  to  surgical  intervention. 

AVhen  the  neoplasm  has  passed  beyond  the  limits  of  the  uterine 
neck  and  the  upper  extremity  of  the  vagina,  it  diffuses  itself  in  the  peri- 
cervical  cellular  tissue;  the  neoplastic  granulations  come  in  contact 
with  the  bladder  and  the  ureters,  comi^ress  them,  adhere  to  them,  and 
invade  them.  These  vesical  adhesions  make  oj^erative  intervention  dif- 
ficult and  may  induce  the  surgeon  to  perform  more  or  less  extensive  re- 
sections of  the  vesical  floor, — resections  which  often  pioduce  the  most 
deplorable  results.  AVe  may,  therefore,  agree  Avith  Cruet,  that  the  con- 
dition of  the  bladder  is  the  determining  factor  as  to  whether  a  cancer 
of  the  uterus  shall  be  operated  uj^on  or  not.  Cystoscopy,  therefore, 
reveals  the  extent  of  the  neoplasm  and  decides  for  us  as  to  the  advisa- 
bility or  the  facility  of  surgical  intervention  applied  to  the  uterus.  By 
showing  that  the  bladder  is  normal,  cystosco]n-  will  determine  the 
character  of  the  o])ei-ati()n  nolwillisiandiiig  niisal  israc1oi\-  clinical  data. 
On  the  other  hand,  cystosco])y  will  reveal  some  cases  to  be  ino])erable, 
when  they  seem  clinically  to  be  o]i(M"able. 


208  CYSTOSCOPY   AND    URETHROSCOPY 

Direct  vision  cystoscopy  is  to  be  preferred  to  any  other  method  of 
examination  of  the  bladder  in  cancer  of  the  uterus.  We  have  constantly 
employed  this  method  in  the  observations  which  Ave  have  mStde,  and 
which  are  mentioned  further  on  (see  page  234). 

REFERENCES 

iLuys:      Verhandl.   d.   deutsch.   Gesellsch.   f.   Urol.,    II    Kongress   in    Berlin,   'Lei'pzig,    Georg 

Thieme,  April  19-22,  1909 ;  Oscar  Coblentz,  Berlin. 
2Cruet:     Ann.  de  gynec,  Jan.  and  Feb.,  1913,  pp.  1  and  70. 
sViolet  and  Murard:     Ee\Tie  de  gynec,  Feb.  1,  1913,  xx.  No.  2,  p.  129. 

Cystoscopy  of  the  Cancerous  Bladder 

Cystoscopy  of  the  bladder  invaded  by  cancer  comprises  the  fol- 
loAving: 

1.  Examination  of  the  vesical  mucosa.  2.  Examination  of  the  ure- 
teral orifices  and  ureteral  ejaculations.  3.  Catheterization  of  the  ure- 
ters and  the  determination  of  the  capacitj^  of  the  renal  pelvis. 

1.  Examination  of  the  Vesical  Mucosa. — 

Vascularization  or  the  Mucosa. — When  the  bladder  is  at  first  in- 
vaded by  the  cancerous  infiltration  which  has  extended  from  the  uterus, 
cystoscopy  brings  into  view  the  changes  which  have  occurred  in  the 
vessels  of  the  mucosa.  These  occur  principally  at  the  vesical  trigone, 
and  consist  in  the  beginning  of  an  increase  in  caliber  and  quantity, 
being  indicated  by  the  presence  of  fine  isolated  hemorrhagic  effusions. 
By  their  cohesion  they  give  the  vesical  mucosa  a  congested  appearance, 
made  evident  by  an  intense  redness,  which  gives  the  vesical  luucosa  a 
dark  ecchymotic  or  perhaps  a  violet  tint.  Here  and  there  small  ulcera- 
tions may  be  observed,  buried  amid  a  red  and  congested  mucosa  and 
showing  minute  hemorrhages  (Plate  XXI,  Fig.  2).  This  explains  the 
ease  with  which  the  mucosa  bleeds  when  it  comes  in  contact  with  a  cot- 
ton carrier  or  with  the  cystoscope.  The  vesical  surface  looks  raw  and 
the  epithelium  is  exfoliated.  This  is  tlie  first  stage  and  may  remain  in 
this  condition  for  a  considerable  period  of  time,  the  lesions  are  usually 
confined  to  the  trigone. 

Edema. — Later  on,  edema  appears  in  a  more  accentuated  degree, 
this  being  the  most  usual  accompaniment  of  cancer  of  the  bladder. 
Edema  is  at  first  indicated  by  the  presence  of  folds  and  swellings,  which 
showing  themselves  first  at  the  trabeculations,  become  more  and  more 
numerous  and  voluminous  and  end  in  the  formation  of  more  or  less 
coherent  edematous  masses.  Most  of  these  edematous  folds  are  found 
behind  the  trigone,  at  the  fundus  of  the  bladder. 

The  cystoscopic  picture  varies  according  to  the  size  and  number 


PATIIOLOdlC    l*,l.AI)i)l';n    SI'IKX    TII  IMiI'I.II     ('\  STOSCOPIi  209 

ol.'  ilic'sc  bodies.  'Tlic  (mIciiijiIous  N'csiclcs  may  he  1 1'aiislucciil  and  llicii' 
size  may  vary  I'l^oin  llial  of  a  ])iidi('ad  lo  a  .L-.rajx'.  .\1  limes  tliey  are  red 
and  ecdiymotic;  at  otlier  times,  they  resemble  gelatinous  balls,  of  a 
li,^'lit  bine  tint;  ag'ain,  tliey  are  joined  too-otlier  and  form  a  whole,  whieh 
Fromnie  has  described  as  resemblinii,'  a  cushion,  l^hey  may  also  be  dis- 
seminated and  separated  by  folds  or  by  less  edematous  ])oi1ions  (Plate 
XXT,  Fig.  1,  and  Plate  XXIV,  Fig.  3)". 

AVhen  the  edema  is  extremely  marked,  it  is  termed  "bullous 
edema,"  first  described  by  KoUischer.  This  consists  of  a  mass  of  clear 
vesicles,  the  dimensions  of  which  vary  between  a  pinhead  and  a  large 
grape. 

Invasion  of  the  Bladder  by  CancePw — Simultaneously  Avith  the 
edema,  invasion  of  the  vesical  mucosa  by  the  cancer  may  'frequently 
be  observed.  This  ajDpears  at  first  in  the  form  of  little  oval  or  round 
plaques  the  size  of  a  pinhead,  resembling  candle  drippings.  Later  on, 
the  granulations  become  more  red  and  constitute  little  nuclei  Avhich 
appear  prominently  on  the  mucous  surface.  Or  the  cancer  may  mani- 
fest itself  in  the  form  of  vegetations  which  form  branching  arboriza- 
tions; these  are  Avell  shown  in  Plate  XXI,  Fig.  1. 

It  is  especially  interesting  to  study  the  onset  of  cancer  of  the 
bladder  with  the  direct  vision  cystoscope.  With  this  instrument  the 
bladder  may  be  seen  not  only  at  full  view  but  in  profile,  and  under 
these  conditions  the  slightest  elevation  of  the  mucous  membrane  can  be 
readily  observed.  In  a  more  advanced  degree,  nuclei  are  formed  in 
the  thick  substance  of  the  vesical  mucosa;  they  are  distinguished  by 
their  hardness  and  opacity,  and  especially  by  the  extreme  facility  with 
wdiich  they  bleed  on  the  slightest  contact. 

Perforation  of  the  Bladder. — When  the  lesion  has  developed  for 
quite  a  long  period,  the  result  is  almost  certainly  a  perforation  of  the 
bladder  communicating  Avith  the  vagina.  This  perforation  aj^pears  in 
the  shape  of  an  ulceration  almost  entirely  concealed  by  edematous 
masses  or  covered  over  by  false,  Avhite  membranes.  These  A^esico- 
vaginal  fistulas  of  cancerous  origin  are  always  indicatiA^e  of  an  unfavor- 
able prognosis. 

Swelling  of  tpie  Bladder  Fundus. — German  authors  have  at- 
tached quite  considerable  importance  to  the  bulging  of  the  fundus  of 
the  bladder,  but  it  does  not  seem  to  me  that  this  curvature  of  the 
A-esical  Avail  has  any  ])articularly  specific  meaning  in  the  diagnosis  of 
secondary  invasion  of  the  bladder  by  cancer.  The  simjile  elevation  of 
the  bladder  fundus  indicates  nothing  ])ut  tlu^  development  of  a  mass 
behind  the  bladder.  This  is  observed  in  pregnancy,  as  Avell  as  in  retro- 
AHM'sion,   lil)roma,  and  cancer.     AVith  the  dii'ect  A'ision  cystoscope  this 


210  CYSTOSCOPY   Ai!^D    URETHROSCOPY 

bulging  is  very  seldom  seen,  because  of  the  reclining  position  of  the 
patient;  in  am^  event  when  it  exists  alone,  it  can  not  be  considered  as  a 
contraindication  to  surgical  intervention. 

2.  Examination  of  the  Ureteral  Orifices  and  Ureteral  Ejaculation. — 
Cystoscop}'  enables  one  to  investigate  the  condition  of  the  ureteral 
orifices  and  of  the  ureters  themselves  Avith  great  precision.  The  ap- 
pearance of  the  orifices  may  be  modified  more  or  less  by  the  presence 
of  edema  of  the  vesical  floor.  These  orifices  may  become  entirely  invis- 
ible, depending  on  the  extent  of  the  edematous  masses.  At  other  times 
the  orifices  are  more  or  less  narrowed,  swollen,  enlarged,  and  their 
edges  edematous.  Enlargement  of  the  ureteral  orifice  often  indicates 
the  presence  of  a  stricture  higher  up  in  the  canal. 

The  study  of  the  ureteral  ejaculation  is  also  of  considerable,  im- 
portance. It  is  best  seen  with  the  direct  vision  cystoscope.  Indeed, 
with  this  instrument  the  emission  can  be  seen  in  profile  in  the  form  of 
a  very  small  jet  of  water;  the  intensity  of  this  emission  denotes  the 
condition  of  the  ureteral  musculature.  The  emission  should  be  stud- 
ied as  to  its  rhythm  and  as  to  its  sti^ength,  1)oth  of  which  are  subject 
to  wide  modifications. 

3.  Catheterization  of  the  Ureters. — ]\Iere  inspection  of  the  ureteral 
orifices  is  not  sufficient;  in  addition,  it  is  well  to  catheterize  both  ure- 
ters with  fine  catheters  whenever  it  is  possible  to  do  so ;  for  in  this  way 
alone  can  we  be  assured  of  the  free  flow  of  urine  in  the  ureters.  Not 
infrequently  in  spite  of  the  normal  appearance  of  the  ureteral  orifices, 
a  No.  5  catheter  is  arrested  two  or  three  centimeters  from  the  orifice. 
This  indicates  that  the  ureter  is  being  compressed  or  invaded  by 
cancerous  infiltration.  When,  in  such  cases,  the  catheter  is  left  in  place 
for  a  few  moments  and  there  is  no  escape  of  urine,  a  complete  obliter- 
ation of  the  ureter  is  indicated,  Avith  exclusion  of  the  kidney. 

In  a  case  observed  in  the  ser^dce  of  Pozzi,  a  patient  Avith  cancer 
of  the  uterus  did  not  in  the  least  suspect  anything  abnormal  Avith  the 
kidney,  for  she  had  ncA^er  felt. anything  Avrong  in  this  connection;  neA^er- 
tlieless,  there  Avas  an  obliteration  of  one  of  the  ureters  Avhich  Avas 
bringing  about  a  complete  functional  destruction  of  one  of  the  kidneys. 

On  the  other  hand,  Avhen  the  catheter  suddenly  produces  a  copi- 
ous floAv  of  urine,  after  liaAdng  progressed  Avith  difficultA"  for  a  feAv 
centimeters  into  the  ureter,  Ave  are  dealing  Avitli  hydronephrosis  due  to 
a  partial  obliteration  of  the  ureter. 

EsTiMATioi>f  OF  THE  CAPACITY  OF  THE  KiDNEY  Pela^s. — Under  the 
circumstances  just  referred  to, — as  I  haA^e  recommended  since  1906,^ 
— an  iuA^estigation  should  be  made  of  the  extent  of  the  hydro- 
nephrosis, by  determining  the  capacity  of  the  renal  i:)elvis;  this  re- 


PATIIOI.MCIC    Iil.ADltKFl    SEEN    '11 1  Ko I 'CH    CYSTOSCOPE  211 

veals  tlic  amouiii  of  dot iiiclioii  of  llic  coiTcsiJOiKliii^-  renal  paroii- 
clixiiia.  This  esliiiiatioii  oT  llic  |)('l\i('  ('a})a('ity  (llic  (lircclioiis  and 
leclinic  of  wliicli  arc  doserihed  later  on)  is  made  hy  injecting-  sterilized 
water  into  the  pelvis  by  means  of  a  ureteral  catlieter  syrin^-o.  AVlien 
Hie  pelvis  becomes  distended,  tbe  patient  feels  a  well-defined  Imnbar 
])ain  wliicli  is  al)S()]utely  eliaraeteristic.  A  note  is  then  made  of  the 
(juantity  of  tlui<l  that  lias  been  injected.  A  normal  pelvis  contains 
about  5  C.C.;  when  more  tlian  10  c.c.  can  Ije  injected,  bydronephrosis  un- 
d()ul)tedh'  exists. 

From  tbe  cystoscopic  examination  practiced  in  a  metbodical  man- 
ner upon  all  patients  with  cancer  of  tbe  uterus,  important  conclusions 
can  be  drawn.  AVitb  this  object  in  view,  we  have  examined  tbirty- 
tbree  i:)atients  witb  uterine  epitbelioma,  in  tbe  service  of  Pozzi,  Avitb 
tbe  following  results: 

The  bladder  Avas  normal  in  seven  cases;  i.  e.,  Nos.  3,  12,  17,  19,  20, 
22,  31.  Among  tbese  seven  cases,  one  is  especially  instructive, — case 
Xo.  20,  in  wbicli  tbe  cancer  bad  involved  tbe  posterior  portion  of  tbe 
uterus  especially,  leaving  tbe  anterior  portion  unaffected. 

Tbe  bladder  Avas  involved,  tbe  fundus  being  sligbtly  inflamed  in 
tbirteen  cases;  i.  e.,  Nos.  1,  2,  4,  9,  13,  16,  21,  23,  24,  26,  28,  29,  33. 

The  bladder  was  invaded  by  tbe  cancer  and  presented,  not  only 
bullous  edema  over  tbe  entire  fundus,  but  also  a  distinct  elevation  of 
tbe  floor,  in  tbirteen  cases;  i.  e.,  Nos.  5,  6,  7,  8,  10,  11,  14,  15,  18,  25,  27, 
30,  32. 

In  one  case,  No.  14,  a  vesicovaginal  fistula  was  noted. 

In  one  case,  No.  25,  we  observed  a  compression  of  tbe  ureteral  ori- 
fices Avitli  distinct  and  important  effect  on  tbe  kidney.  Tbis  case  is 
an  im^Dortant  one,  for  tbis  complication  miglit  pass  completely  un- 
noticed if  proper  care  is  not  observed  in  tbe  matter.  Tbe  conclusions 
resulting  from  tbe  cystoscopic  examinations  in  tbese  cases  are  as  fol- 
io avs  : 

Conclusions. — 1.  Bladder  cystoscopy  sbould  l)e  performed  in  all 
cases  of  uterine  cancer,  not  only  from  tbe  standpoint  of  operative  prog- 
nosis, but  also  as  an  indication  or  contraindication  for  surgical  inter- 
vention. 

2.  If  tbe  blad<ler  is  free  from  all  lesions  or  presents  only  a  dif- 
fused redness  or  a  sligbt  bloody  suffusion,  operation  is  indicated  and 
will  not  be  difficult. 

3.  If  tbe  bladder  is  somewbat  involved,  if  little  idcerations  of  tbe 
nuicosa  and  well-marbed  vascularization  are  observed,  tbe  surgeon 
may  expect  tbat  abdominal  bysterectomy  will  l)e  a  difficult  matter. 

4.  If,  finallv,  tbe  bladder  is  decidedlv  attacked  bv  edema  or  by  can- 


212  CYSTOSCOPY   AXD    UEETHEOSCOPY 

cer  itself,  or  b}^  a  vesical  perforation,  tliese  must  be  considered  as  a 
contraindication  to  abdominal  hysterectomy  wliicli  can  onh"  be  done 
witli  extensive  resections  of  tlie  vesical  wall.  *^ 

5.  If  the  ureters  have  become  impermeable  through  ureteral  com- 
pression by  cancer  of  the  uterus,  or  if  they  become  invisible  because  of 
the  accomiDan^dng  edema,  operation  is  absolutely  contraindicated. 

The  following  observations,  the  result  of  experience  in  the  service 
of  Pozzi  at  the  Broca  Hospital,  have  been  published  in  greater  detail 
in  the  thesis  of  M.  Colaneri:^ 

Case  1.— Widow  B.,  aged  fortT-five. 

Exammation  of  the  Uterus. — Xeck  ulcerated,  irregular,  jagged,  indurated,  bleeding 
easily,  painful;   slightly  mobile. 

Cystoscopy. — Fundus  congested  with  red  elevations  as  large  as  grapes,  bleeding  easily, 
indicating  that  the  bladder  is  involved. 

Ureteral  Orifices.— The  right  is  quite  small,  a  No.  5  catheter  shows  the  ureter  is  patent 
and  free;  the  left  is  quite  small,  a  No.  6  catheter  enters  freely. 

Treatment. — Total  abdominal  hysterectomy.  Uterus  adherent  anteriorly  to  the  ex- 
treme limit  of  operability;  uterine  body  separated  from  the  neck  during  operation;  ureters 
hard  to  find.     Death  the  following  day. 

Case  2. — F.,  aged  forty-four. 

Examination  of   Uterus. — Nodular,  but   does  not   bleed. 

Cystoscopy. — Normal  bladder  capacity;  fundus  distinctly  red;  bladder  is  slightly  af- 
fected;  ureteral   orifices  normal;   catheterization  normal. 

Treatment. — Usual;    complete  vaginal  hysterectomy.     Went   home  in  three  weeks. 

Case  3.— T.,  aged  fifty-one. 

Cystoscopy. — Bladder  and  ureteral  orifices  normal;   on  the  left  side,  a  No.  6  catheter 
is  arrested  slightly  at  3  centimeters,  but  passes  higher  up,  though  with  some  difficulty. 
Treatmient. — No   operation;   went  home. 

Case  4. — V.,  aged  fifty-two. 

Cystoscopy. — The  fundus  is  markedly  congested  and  bleeds  at  the  slightest  contact. 
Ureters  are  free;   bladder  is  involved.     Passed  from  observation. 

Case  5. — Z.,  aged  fifty. 

Cystoscopy. — The  right  fundus  presents  a  few  edematous  masses  near  the  right  ureter ; 
both  ureters  are  small,  but  permeable  to  No.  5  catheters.     The  bladder  is  involved. 
Treatment. — No  operation;   patient  left  the  hospital. 

Case  6. — ^E>.,  aged  forty-three. 

Cystoscopy.- — -Bladder  capacity  normal;  at  the  fundus  in  the  median  line  are  found  a 
hard  elevation,  hyperemia,  congested  mucosa  with  whitish  vegetations  which  bleed  at  the 
slightest  contact;  on  the  lateral  portions  are  edematous  masses  varying  in  size  from  a  hemp 
seed  to  a  large  pea.  Tliese  masses  cover  a  large  part  of  the  fundus  and  completely  conceal 
the  orifices  of  the  ureters,  which  therefore  can  not  be  catheterized.     The  bladder  is  involved. 

Treatment. — No  operation;   went  home  in  fifteen  days. 

Case  7. — C,  aged  forty-one. 

Examination  of  Uterus. — Ligneous  infiltration  of  two-thirds  of  the  vaginal  circumfer- 
ence; neck  effaced. 


PATHOLOGIC    BLADDER    SEEX    THROUGH    CYSTOSCOPE  213 

Cystoscopy. — Edematous  globules  on  the  bladder  floor;  entire  fundus  is  edematous; 
right  ureteral  orifice  is  noimal  and  readily  accepts  a  No.  7  catheter;  left  orifice  is  over- 
hung by  edematous  masses  which  conceal  it  and  make  catheterization  impossible. 

Treatment. — "Warm  air;  no  operation;  died  a  year  later. 

Case  8. — M.,  aged  forty-one. 

Examination  of  Uterus. — Xeck  is  hard,  very  much  increased  in  size;  anterior  lij)  over- 
hangs the  posterior ;   the  orifice  is  linear,   friable,   and  gives  evidence   of  bloody  debris. 

Cystoscopy. — Bladder  capacity  normal;  on  the  fundus  and  the  median  line  are  large, 
transverse  swellings  of  glossy  edema;  the  remainder  of  the  fundus  has  a  granular  aspect; 
the  bladder  is  involved;  the  right  ureteral  orifice  accepts  a  No.  6  catheter;  the  left  is  sur- 
rounded with  a  placque  of  leucoplakia  but  easily  accepts  a  No.   7  catheter. 

Treatment. — Complete  abdominal  hysterectomy;  no  marked  adhesions;  slight  bleed- 
ing; died  the  following  day. 

Case  9. — B.,  aged  forty-two. 

Examination    of    Uterus. — Enormous    neck,    hardened;    uterus    retroverted. 
Cystoscopy. — A  diffused,  generalized  edema  covers  the  fundus;  the  bladder  is  involved; 
ureteral  orifices  are  small;    double  catheterization  is  easy. 

Treatment. — No   operation;   hot-air   applications;    went  home   a  mouth  later. 

Case  10. — H.,  aged  thirty-six. 

Exa/mination    of    Uterus. — Neck   ulcerated    and    bleeding;    uterus    immobilized. 

Cystoscopy. — The  fundus  is  involved  in  glossy  bullous  edema,  wliich  bleeds  at  the 
slightest  contact ;  urine  is  clear ;  the  bladder  is  involved ;  right  ureter  is  somewhat  swollen ; 
a  No.  6  catheter  passes  easily;  the  left  is  surrounded  by  masses  of  bleeding  edema;  catheter- 
ization is  impossible. 

Treatment. — No   operation;   left   ten   days  later. 

Case  11. — B.  M.,  aged  thirty-four.     Clinically,  epithelioma  of  uterus. 
Cystoscopy. — The  fundus  presents  numerous  edematous  globules  with  hemorrhagic  spots; 
bladder   is   involved;    ureteral   orifices    can   not   be    seen.     No    treatment. 

Case  12.— C.  M. 

Cystoscopy. — Urine  is  clear;  bladder  normal,  with  normal  caj^acity;  fundus  and  ureteral 
orifices  normal;   the  left  is  simply  a  little  elevated  and  enlarged. 

Case  13. — T.  J.,  aged  twenty-eight. 

Examination  of  Uterus. — A  vegetating  tumor,  which  occupies  both  lips  of  the  neck, 
irregular,  embossed,  resting  on  an  indurated  base;  the  tumor  is  extending  toward  the  left 
lateral  cul-de-sac,  where  the  uterus  is  fixed,  though  movable  elsewhere;  bloody  debris. 

Cystoscopy. — Bloody' ecchjTnoses  at  the  neck;  fundus  is  distinctly  red;  between  the 
ureters  is  a  clearly  detined  inflammatory  redness;  the  bladder  is  involved;  ureteral  orifices 
are  normal,  with  feeble  but  normal  emissions. 

Treatment. — Oct.  16,  1908,  curettage;  cauterization.  Nov.  10,  1908:  Total  abdominal 
hysterecomy;  dissection  of  ureters  adherent  to  the  parametrium  and  uterus;  they  had  to 
be  dissected  with  the  knife;  separation  from  the*  bladder  difficult.     Kecovery  in  five  weeks. 

Case  14. — G.,  aged  thirty-three. 

Examination  of  Uterus. — Vaginal  fundus  indurated;  cancerous  buds,  bleeding  easily; 
vesicovaginal  fistula  invisible,  but  prolialjly  situated  at  the  left  in  the  midst  of  the  most 
numerous  fungosities. 

Cystoscopy. — Urine  is  cloudy;  no  bladder  capacity  because  of  the  vesicovaginal  fistula; 
the  fundus  is  invaded  by  the  neoplasm  and  by  numerous  globules  of  edema;  the  bladder 
is  greatly  involved,  except  the  roof,  which  is  nornuil;  ureteral  orifices  concealed  by  the 
fungoids  which  surround  them. 


PLATE  XIII 

Fig.  1. — Appearance  of  a  ureteral  orifice  in  pregnancy.  The  ureteral  ori- 
fice, displaced  by  the  fetal  head,  is  situated  higher  than  in  the  normal 
state;  laterally  a  long  j^assage  which  represents  the  right  lateral  side 
of  the  bladder  is  seen. 

Fig.  2. — Normal  appearance  of  a  ureteral  orifice  seen  with  the  direct  vision 
cystoscope,  and  isolated  in  the  lumen  of  the  cystoscopic  tube. 

Fig.  3. — Ureteral  emission  of  normal  urine  as  seen  with  the  direct  vision 
cystoscope. 

Fig.  4. — Direct  catheterization  of  the  ureter  with  the  direct  vision  cysto- 
scope. The  fact  that  the  catheter  has  penetrated  well  into  the  ureter 
can  be  verified  by  the  double  fact  that  it  is  fully  surrounded  with 
mucosa,  and  that  the  vesical  mucosa  is  slightly  puffed  up  around  it. 

Fig.  5. — Tra'beculated  bladder.     Typical  view. 

Fig.  6. — Urethrovesicovaginal  fistula.  View  of  the  neck  of  the  Madder.  In 
the  upper  part  of  the  figure  the  floor  of  the  normal  bladder  is  recog- 
nized in  the  distance,  very  poorly  lighted;  it  is  surrounded  by  the 
bladder  neck,  which  is  slightly  furrowed  and  edematous.  To  the  right, 
lateral  side  of  the  vesical  neck  (to  the  left  of  the  oliserver),  a  large 
oblique  orifice  with  edematous  walls  is  seen,  through  which  a  catheter 
can  penetrate.  This  orifice  leads  into  a  passage  which,  turning  around 
the  right  side  of  the  vesical  neck,  enters  the  bladder  at  the  vesico- 
vaginal region,  thus  constituting  a  real  fistula. 


Fig.  1. 


Fig.  2. 


Fig.  3. 


Fig.  4. 


Fig.  5. 


PLATE  XIII 


Fig.  6. 


i'.\'i'ii()i-()(;i('   i;lai)|ii;i;  si;I';x   tii  iiorcii   ('\'st()sc"()PI':  215 

Tn  III  niciil.      '\\\ tlis    |iic\  iuiisly,    tiit;il    ;i  lulnin  i  ii;i  I    li  yst  cici-l  uiii  y    li;i<l    Imtm    iirrCiii-nK'd, 

J'lir    very    :iil\  ii  iiri'd    ciiil  licliniii;!    (if    llic    neck;    tlic    left    iiirlcr    \vas   distciidcd    hchiiid    its    i>()iiit 

III'   |iciicl  nil  inn    ill    tile    liiii;iil    linn lit;    riiiHici-  dii,   lilifiMin    in   size  and   adlirront  to   tlic  mass. 

Krsccti r    (lie    iiirlrr    iiiid    a ii;isl iiiiMisis    iiilii    llic    liladdcr    wiiiTc    Hir    VL'sical    rcsc'i-tiun    liad 

IjCL'IL    dniU'. 

Two  nidiitlis  later:  Rcadiiii-  and  jiassiii;;-  licyniid  llic  alTrctcd  ;nca  is  iinpossihlc ; 
lips  of  tistula  sutuii'd;    tiu'iiiKu-aulcii/.tit  inn   of   the   Inids.      Went    Ikmih'    four   iiiontlis   later. 

Case  15. — C.  Z.,  aj;ed  forty-seven. 

Examination   of   Uterus. — Neck   covcied   with    IukIs;    lilcrdin;;. 

Ci/sloscoiiii. — A  liaiid  nf  edema  is  clearly  seen  on  the  intcrureteral  muscle  (li^iinient) 
half  a  centimeter  in  length;  also  some  edematous  masses  no  larger  than  a  hempseed.  The 
Madder  is  involved. 

Treatment. — Curettage   and    cauterization;    went    homo   a    nidiitli   later. 

Case  16. — D.  J.,  aged  twenty-eight. 

E.mmination  of  Uterus. — Neck  irregular  and  hard,  espcidally  the  anteridr  liji;  uteius 
not  increased  in  size,  slightly  mobile;  cul-de-sac  negative. 

Cystoscopy. — Within  the  left  ureteral  orifice,  which  is  normal,  there  are  a  few  de- 
tached globules  of  edema  the  size  of  a'  millet  grain,  upon  an  abnormally  red  base;  the 
bladder  invasion  is  extremely  limited  and  in  its  incipiency. 

Ureteral  Orifices. — The  right  is  normal;  the  left  has  some  edematous  masses  around 
it ;  emissions  normal ;  urine  is  clear. 

Treatment. — Total  abdominal  hysterectomy.  Easy  dissection  of  the  ureters  and  blad- 
der, the  latter  very  adherent.     Went  home  one  month  later. 

Case   17. — R.,   aged   sixty-five. 

Examination  of  Uterus. — Painful ;  the  neck  forms  a  crater  with  torn  and  bleeding 
edges;  uterus  is  immobile. 

Cystoscopy. — The  mucosa  of  the  fundus  is  contracted  and  in  folds,  but  appears  normal ; 
no  edema;  the  right  ureteral  orifice  is  normal;  the  left  shows  some  light  false  membranes; 
urinary  secretion  is  the  same  on  both  sides,  this  being  verified  by  the  use  of  the  separator 
(Luys). 

Treatment. — No  operation.    Went  home  two  months  later. 

Case  IS. — L.  J.,  aged  forty-six. 

Cystoscopy. — The  urine  is  cloudy;  the  fundus  is  edematous  in  jiarallel  grooves  and 
bleeds  easily;  it  is  elevated  en  masse,  so  that  the  cystoscope  must  be  depressed  considerably 
to  enter  the  bladder.  The  bladder  is  therefore  involved;  only  the  roof  is  normal,  and  .shows 
no  abnormal  va.scularization ;  the  ureteral  orifices  are  invisible,  being  hidden  liy  the  edema, 
which  has  spread  out   over  the   entire  fundus.      No  treatment. 

Case  19. — P.,  aged  forty-seven.     A   characteristic  uterine  neoidasm. 

Cystoseopi/. — The  urine  is  clear;  the  bladder  and  ureteral  orifices  are  normal.  Case 
not  f(dlowed  up. 

Case  20. — V.,  aged  forty.  Six  months  previously  underwent  removal  of  the  neck  of 
uterus  because  of  ulceration.  After  this  operation  a  fetid  discharge  and  pain  persisted. 
Manually,  it  was  found  that  the  posterior  lip  of  the  neck  was  completely  ulcerated  and 
that  the  obstruction  reached  the  rectovaginal  wall.  In  additimi,  hard  masses  cduld  be  felt 
in  the  broad  ligament.  Uterus,  iinnidbile.  This  examinnt imi  slmwed  thai  the  anterior  aspect 
of  the  uterus  was  not  involved,  but  that  the  cancer  had  devehiped  pai  t  iciilmly  along  the 
]i(isteri(ir  surface  of  the  organ. 

Cystoscopy. — The  bladder   is  quite    noimal;    the    fundus   but    slightly   reddened;    ureteral 


216  CYSTOSCOPY  a:sd  ueethroscopy 

orifices  entirely  normal.  In  this  case,  therefore,  the  cancer  had  invaded  the  posterior  por- 
tion of  the  uterus,  leaving  the  anterior  portion  unattacked.  Both  examinations,  manual  and 
cystoscopic,  agreed  in  the  findings.  This  patient  was  not  oj)erated  on,  and  death  followed 
two  months  later.  **■ 

Case  21. — E.,  aged  thirty-nine.     Clinically,  a  neoplasm  of  the  neck  of  the  uterus. 
Cystoscopy. — The  fundus  is  slightly  inflamed,  especially  on  the  right  side;  right  ureteral 
orifice  is  not  well  defined;   it  has  torn  and  red   edges.     Case  not  followed  up. 

Case  22.— F.,  aged  forty-three. 

Examination  of  Uterus. — Neck  fungous;   culs-de-sac  invaded. 

Cystoscopy. — Urine  is  clear;  the  bladder  is  normal  and  has  normal  capacity;  ureteral 
orifices  also  normal. 

Treatment. — No   operation;    hot-air   applications;    curettage.     Went   home. 

Case  23. — S.,  aged  forty-eight. 

Examination  of  Uterus. — Large  neck  with  indurated  areas ;  uterus  is  mobile ;  the 
broad  ligament  does  not  seem  to  be  involved. 

Cystoscopy. — The  fundus  is  noiinal  except  for  some  small  elevations  resembling  grains 
of  sand,  which  are  usually  met  with  in  chronic  cystitis.  The  roof  of  the  bladder,  on  the 
other  hand,  presents  numerous  bright  red  spots  about  the  size  of  a  dime,  and  resembling 
purpura.     The  ureteral  orifices   are  normal. 

Treatment. — Total  abdominal  hysterectomy;  dissection  of  the  anterior  uterine  wall  up 
to  the  vaginal  cul-de-sac;  severe  hemorrhage  followed;  difficult  hemostasis.  Went  home  two 
months  later. 

Examination  three  years  after  operation:  The  purpura  has  disappeared;  the  bladder 
is  normal. 

Case  24. — E.,  aged  thirty-four. 

Examination  of  Uterus. — In  the  vagina,  an  enormous  mass,  budding  and  hard;  the  culs- 
de-sac  are  completely  invaded,  especially  the  right. 

Cystoscopy. — The  urine  is  slightly  hazy;  bladder  capacity  normal;  the  right  fundus 
is  slightly  elevated;  on  the  same  side  are  edematous  masses,  some  of  which  are  ulcerated, 
this  being  an  indication  of  bladder  involvement;  both  ureteral'  orifices  are  in  contact  'with 
these  masses. 

Treatment. — Curettage  and  cauterization.     Went  home. 

Case  25. — D.,  aged  sixty. 

Cystoscopy. — The  trigone  is  invaded  with  a  red  tissue,  with  whitish  ulcerated  buds 
and  bleeding  easily;  the  urine  is  cloudy  and  the  bladder  is  invaded;  the  right  ureteral  orifice 
is  barely  visible  in  the  midst  of  neoplastic  tissue;  catheterization  is  impossible;  the  right 
kidney  is  plainly  increased  in  size;   the  left  ureteral   orifice  is  normal. 

In  this   case  there  was   a   distinct   contraindication   to   operation. 

Case  26.— F.  S.,  aged  thirty-one. 

Examination  of  Uterus. — The  neck  is  vegetating  and  bleeding. 

Cystoscopy. — The  trigone  is  bright  red  and  elevated;  slight  elevations,  somewhat  paler, 
stand  out  prominently  against  a  background  of  hemorrhagic  spots;  the  bladder  is  but 
slightly  invaded;  the  ureteral  orifices  are  normal. 

Treatment. — Curettage   and   cauterization.     Went  home. 

Case  27. — L.,  aged  forty-five.     Neoplasm  of  the  uterine  neck. 

Cystoscopy. — The  urine  is  clear;  the  fundus  presents  an  intense  generalized  edema, 
contrasting  with  the  glossy  whiteness  of  the  normal  roof  of  the  bladder;  the  bladder  is 
undoubtedly  invaded  and  painful;   the  ureteral  orifices  are  invisible.     No   treatment. 


PATIIOLOCIC    JILAItDKIt    SliEN    Tl  I  IM  )  I  ( i  1 1     (   ^  S'lOSCOPE  LM  7 

Casio  2S. — 11.,  ajicd  .sixt.y-oiic.     Caiifor  of   tlic   nli'iinc   nci-k. 

Ci/s-toscopij. — The  uriuo  is  dear;  the  l)lail<lri  Hour  is  hij^lily  vasfuilarizcd,  ffathcrod  in 
folds  and  Jidhcront,  irscndjliiii;-  tho  intestinal  nuiss;  the  hlailder  is  evidently  involved;  ureteral 
orifices  are   humikiI.     Xu   t  icat  nu'iif . 

Case  29.— B.,  aged  forty-two. 

Exaviination  of  Vtcrus. — Neck  situated  rather  hij;li  up,  hard  and  sclerotic;  on  the 
anterior  lip  are  many  buds,  separated  one  from  another  by  ulcers  whidi  Ideed  very  easily; 
culs-de-sac  free,  except  at  the  left,  where  there  is  a  slight  thickening. 

Cystoscopy. — The  bladder  capacity  is  normal ;  it  is  slightly  invaded  by  neoplastic  in- 
filtration; the  trigone  is  slightly  elevated  and  presents  a  hemorrhagic  spot;  the  ureteral 
orifices  are  normal;  nothing  from  the  bladder  point  of  view  seems  to  contraindicate  operation. 

Treatment. — Complete  abdominal  hysterectomy;  the  left  adnexa  adherent;  isolation  of 
the  ureter;  sc|)aration  of  the  bladder  and  di.sscction  by  scissors  of  the  lower  extremity  of 
the  ureters.     Went  home  seven  weeks  later. 

Case  30. — B.,  aged  forty-four. 

Cystoscopy. — Urine  is  cloudy;  the  l)ladder  capacity  is  10  c.c. ;  the  fundus  is  markedly 
edematous;  the  bladder  is  affected;  the  right  ureteral  orifice  is  invisible  in  the  midst  of 
the  edema. 

Case  31. — L.,  aged  forty-nine.  Cancer  of  the  uterus.  Has  been  referred  to  determine 
whether  the  bladder  is  involved. 

Cystoscopy. — The  bladder  is  normal,  bat  presents  numerous  traljcculatiuns;  the  ureteral 
orifices  are  normal. 

Case  32. — B.,  aged  thirty-eight.  Operated  on  by  Robineau,  l)y  the  vaginal  route,  for 
an  epithelioma  of  the  uterine  body. 

Cystoscopy. — Diffuse  infiltration  of  the  vesical  mucosa  at  the  fundus;  liehind  the  fundus, 
highly  edematous  folds  of  the  vesical  mucosa  are  seen,  which  give  the  appearance  of  a  large 
edematous  cushion;  the  entire  left  side  of  the  bladder  is  normal;  two  little  transparent  cystic 
vesicles  are  seen  on  the  left  lateral  portion  of  the  vesical  neck;  the  ureteral  orifices  are  normal. 

Treatment. — Local  treatment  of  the  bladder  by  applications  of  strong  resorcin,  with 
the  direct  vision  cystoscope. 

Case  33. — Iv.,  aged  fifty-two.  Eeforrcd  to  determine  whetlier  site  has  a  neoplasm  in 
the  bladder. 

Cystoscopy. — The  bladder  has  a  capacity  of  150  c.c;  tiic  uiinc  is  clear;  the  fundus  is 
slightly  infiltrated,  congested  and  downy;  the  ureteral  orifices  arc  normal;  the  bladder  is, 
tlierefore,  but  slightly  involved. 

EEFERElirCES 

iLuys:     De  la  mesurc  de  la  capacite  du  bassinet,  Ann.  d.  inal.  d.  org.  genito-urin.,   lOOli,  ii, 

p.  519. 
-Colaneri,   X.:      De   la   valeur   de   rexameii   de   la   vessie   daiis   le   cancer   de    1 'uteru.'^,   Tliese, 

Paris,  Steinheil,  Editor,  1913. 


CHAPTEE  VI 
DIRECT  VISION  CYSTOSCOPY 

Direct  vision  cystoscoiDy  is  the  study  of  tlie  vesical  mucosa  under 
the  direct  control  of  the  e^^e  Avithout  the  aid  of  the  prism  or  of  any 
special  optical  apparatus. 

Under  this  head  we  shall  consider:  1,  The  conditions  necessary 
for  the  study  of  direct  vision  cystoscopy.  2.  The  teclmic.  3.  The  ad- 
vantages.   4.  The  disadvantages  of  this  method. 

CONDITIONS  NECESSARY  FOR  DIRECT  VISION 
CYSTOSCOPY 

In  order  to  see  an  object  well  in  all  its  details,  it  is  essential  that 
(1)  it  should  he  well  illuminated;  (2)  it  should  be  well  isolated  from 
the  surrounding  jDortions;  (3)  its  surface  should  not  be  covered  over 
by  any  fluid  so  that  there  may  be  a  homogeneous  medium  between 
the  eye  and  the  object,  without  change  of  the  index  of  refraction;  and 
(4)  the  smallest  details  should  l^e  distinguishable. 

Bearing  these  conditions  in  mind,  there  are  four  essentials  to  a 
good  view  of  the  vesical  mucosa,  as  follows:  1.  Projoer  illumination. 
2.  Distention  of  the  vesical  walls.  3.  Aspiration  of  the  urine  as  fast  as 
it  enters  the, bladder.    4.  Magnification  of  the  image. 

1.  Proper  Illumination. — It  goes  without  saying  that  an  internal 
source  of  illumination,  brought  as  closely  as  possible  to  the  object  to  be 
examined,  is  by  far  the  most  desirable  method  at  our  command.  I 
have  made  a  series  of  experiments  in  order  to  assure  myself  of  this 
fact.  Holding  a  simple  tube  vertically,  I  projected  into  it  the  rays  from 
a  very  powerful  electric  light  situated  outside  of  the  tube.  I  thus  ob- 
tained an  illumination  which  gave  a  modei'ately  good  view  at  the 
lower  end  of  the  tube.  On  the  other  hand,  I  placed  a  very  small  lamp 
at  the  point  to  be  examined,  and  obtained  a  very  fine  illumination,  more 
intense  than  previously.  It  was  quite  natural  to  expect  that  this  ar- 
rangement would  furnish  a  much  better  illumination  than  that  pro- 
vided by  an  external  source,  such  as  a  frontal  head  lamp,  for  example. 

For  the  illumination  of  my  cystoscope,  I  then  adopted  the  prin- 
ciple of  the  small  electric  lamp  situated  at  the  vesical  extremity  of 

218 


DIRECT    VISIOX    CYSTOSCOPY  219 

the  cystosco])ic  lulx'.     I   li;iv<'  (M.iili-ihulcd  the  following  iiiipi-ovements 
to  this  nietliod  of  illuiiiiiialioii : 

'Pile  lamp  is  nci'v  small  wliilc  its  luiiiii)oii<  intensity  is  superior 
to  those  loniuM-ly  used;  not  only  does  it  iilunriiiate  the  portion  of  the 
mucosa  Avliich  is  in  direct  contact  witli  the  extremity  of  the  tuhe, 
but  it  also  projects  luminous  rays  beyond  tlie  tube.  When  the  Madder 
walls  are  distended,  ^vitll  the  patient  in  the  inclined  position,  tliey  are 
fully  illuminated,  so  that  a  distinct  and  clear-cut  examination  of  tlie 
entire  bladder  is  made  possible.     (Figs.  149-150.) 

The  lamps,  mounted  on  fine  rods,  are  very  easy  to  handle,  and 
can  be  changed  in  a  few  seconds. 

They  are  attached  to  a  metallic  cap,  filled  with  a  nonconducting 
material,  so  that  fluid  can  not  penetrate  and  thus  produce  a  short 
circuit. 

They  have  a  voltage  of  two  volts,  and  when  new,  are  al)solutely 
"cold."  They  can  be  kept  lighted  between  the  fingers  without  any 
appreciable  heat  being  felt. 

2.  Distention  of  the  Vesical  Walls.— This  may  be  attained  by  ele- 
vating the  bladder  region  so  that  the  abdominal  contents  may  drop 
towards  the  diaphragm.  In  this  position,  a  vacuum  is  formed  in  the 
lesser  pelvis;  the  hypogastrium  is  retracted,  causing  this  vacuum. 
Therefore  when  an  empty  tube  is  inserted  into  the  bladder,  the  air 
rushes  in  and  fills  it  completely,  thus  causing  dilatation  of  the  viscus. 

This  method  is  preferable  to  that  of  injecting  air  into  the  vesical 
cavity  under  pressure.  The  latter  method,  recommended  for  more 
than  ten  years  by  Nitze,  has  been  completely  abandoned  since  then 
by  its  author,  on  account  of  its  nianx  disadvantages.^ 

In  order  to  elevate  the  bladder  and  cause  its  distention,  two  pro- 
cedures may  be  adopted: 

Kelly  and  other  American  surgeons  place  the  patient  in  the  genu- 
pectoral  position;  but  this  position  is  fatiguing  to  the  patient  and  un- 
comfortable for  the  surgeon.  It  seems  more  practical  to  place  the 
woman  in  the  Trendelenlmrg  position,  for  example,  and  supporting 
her  shoulders.  The  idea  of  using  shoulder  props  to  sustain  the  weight 
of  the  body  and  permitting  a  comfortable  gynecologic  examination  in 
the  inclined  position,  was  first  suggested  by  Jayle,  in  1897.'  It  is  but 
an  act  of  justice  to  term  this  position  the  "inclined  position  of  Jayle." 

It  may  be  said  that  the  vesical  wall  is  readily  distended  when  the 
bladder  is  normal  or  not  seriously  diseased,  or  when  the  patient  is 
not  too  obese;  but  when  the  fundus  is  inflamed  and  the  vesical  walls 
are  contracted,  the  distention  is  far  from  satisfactory.    "When  the  cysto- 


220 


CYSTOSCOPY   AND    URETHROSCOPY 


scope  is  properly  handled,  however,  the  entire  mucosa  can  be  examined. 

Satisfactory  distention  of  the  bladder  is  obtained  by  having  the 

patient  breathe  Avith  the  chest  only,  and  not  with  the  abdomen;  tliat  is, 


Fig.   138. — Genupectoral   position   adopted    by    Kelly    for    endoscopic    examination   in   the    male    (Kelly). 

to  have  the  patient  use  the  superior  costal  muscles  and  not  the  dia- 
phragm. During  the  costal  inspiration,  the  abdomen  retracts  and 
favors  the  dilatation  of  the  bladder.    On  the  other  hand,  during  dia- 


Fig.    139. — Method    of   introduction    of    Kelly's   endoscopic    tube    in    the    male    (Kelly). 


phragmatic  inspiration,  the  intestinal  mass  is  pushed  downward  and 
actually  prevents  vesical   distention.     Perfect   dilatation  can,   there- 


miM'U'T  vision:  (•^■sTos('OPv 


221 


fore,  be  seciircil  !)y  iiislnidini;,'  pnllfiils  as  to  1li<'ii-  i-('S|)ira1  ion  before 
tlio  cxniniiiniioii. 


Fig.    140. — 111   tlie  inclined   position,   the  intestinal   mass   is   drawn   toward   the   diaphragm   in   the   direction   oi 
the  arrow  B,   but  not  backward  because   of  the  presence   of  the  vertebral   column. 

In  certain  very  obese  joatients  even  under  chloroform  anesthesia, 
vesical  distention  is  obtained  only  nnder  great  difficulty  in  the  reclin- 


Fig.  141. — In  the  genui)ectoral  position,  the  intestinal  mass  is  not  only  drawn  toward  the  diaphragm 
in  the  direction  of  the  arrow  B,  but  also  forward  in  the  direction  of  the  arrow  A.  The  free  space  indi- 
cated by  the  double  arrow  < >   is  much  greater  in  this  position  than  in  the  preceding  one. 


ing  position   because   ol'  llie  abdoiniiial   i)leibora.     In   sucli   cases,   the 
genupectoral  position  reconnnended  by  Kelly  may  liave  to  be  adopted. 


222 


CYSTOSCOPY   AXD    rEETHROSCOPY 


It  must  l)e  admitted  in  this  connection,  tliat  the  dilatation  of  tlie  blad- 
der is  greater  in  this  position  than  in  the  reclining  position  (Figs.  138- 
139). 

In  the  genupectoral  position,  the  intestinal  mass  has  two  direc- 
tions of  movement  which  permit  the  dilatation  of, the  bladder, — one  for- 
ward, at  the  expense  of  the  supple  abdominal  Avail  and  Avithont  opiDO- 
sition,  and  the  other  npAvard,  in  the  direction  of  the  diaphragm.  In 
the  inclined  jDosition,  on  the  other  hand,  the  intestinal  mass  has  but 
one  Avay  of  escape,  i.  e.,  toward  the  diaphragm.  The  vertebral  colnmn 
as  comjDared  Avitli  the  abdominal  AYall,  is  iixed  in  its  position,  and  can 


Fig.  142. — First  step  in  the  examination  of  the  bladder  in  the  genupectoral  position  in  the  male. 
The  cystoscopic  tube  is  fiist  introduced  with  its  elbowed  obturator,  wh'-le  the  patient  is  in  the^  horizon- 
tal position;  this  having  been  done,  the  patient  is  asked  to  turn  over  gentlv  and  place  himself  in  the  genu- 
pectoral position   (see  Fig.   143). 


not  undergo  any  displacement.  We  may  therefore  saj  that  the  genu- 
pectoral jDosition  furnishes  a  more  satisfactor}^  distention  of  the  blad- 
der and  must  be  resorted  to  Avhen  the  inclined  position  for  one  reason  or 
another,  is  not  satisfactory. 

EA^en  in  the  male,  Avhen  direct  Adsion  cystoscopy  is  indicated,  but 
Avlien  the  bladder  can  not  be  couA^eniently  dilated  in  the  inclined  posi- 
tion because  of  extreme  embonjDoint,  it  may  be  Avell  to  use  the  genupec- 
toral position.  The  latter  seems  at  iirst,  quite  difficult  to  attain,  but  it 
can  be  done  easil}^  if  Ave  proceed  methodically.  The  cystoscope  is  intro- 
duced Avith  the  patient  on  his  back  (Fig.  112) ;  then,  the  surgeon  hold- 


DIIM'XT    VISION    CVSTOSCOPV  Tl.i 

iiiU'  the  ins1  niiiiciil   /';/  siln,  tlic  jjaliciil   is  i-c(|U('sted  to  turn  over  very 
sl()\vl\-,  placiii.u-  liiiiiscir  liiially  in  the  ,u('iiiij)i'('1()i';\l  ])ositioii,  as  slio^vii  in 

Ill  one  iiislaiK'c,  this  inaiiciuc!'  was  especially  nselul  to  one  of  my 
patients,  '^riic  !<  11  kidney  had  l)een  removed  for  tulx'i-eidous  pyonepliro- 
sis.  After  tiu'  ()])eration,  vesical  lesions  j^ersisted  with  symptoms  of 
marked  cystitis.  Indirect  cystoscopy  showed  two  plaques  of  tul)er- 
culous  cystitis  (•ir('uiiiscril)ed  clearly  on  the  upper  l)hidder  wall.  I 
placed  liiiii  in  tlie  ,i;('iin]X'ctoi-al  position  and  ol)taine(l  an  excellent  dila- 
tation of  the  hladder.  AVitli  niy  direct  vision  cystoscope  I  saw  the  in- 
flammatory i)]aques  on  the  upjier  wall  (Plate  XVI,  Figs.  2  and  o),  and 


Fig.   143. — Local   treatment   of   cystitis   in   the   male,    ir.    the   genupectoral   position. 

was  enahled  to  make  direct  applications  of  lactic  acid  solution  which 
resulted  in  a  decided  improvement. 

KEFEEEITCES 

iNitzo:     Lehrbuch  der  Kystocopie,  1889,  pp.  SO,  81. 

2Jayle:     Prcsse  mod.,  June  22,  1808,  p.  336;  also  Feb.  15,  l>;!i<i.  Xo.  l.*".,  p.  79;  Rev.  de  s.vnec. 
et  do  chir.  abd.,  April  10,  1899,  No.  2,  p.  314. 


o.  Aspiration  of  the  Urine. — The  constant  secretion  of  urine 
through  llio  ureters  makes  it  iiiqiossihle  to  ohtaiii  a  dry  mucosa  for  a 
proper  examination.  The  urinary  secretion  takes  place  so  rpuckly  that 
it  is  difficult  to  make  an  examination  between  the  applications  of  the 
swal).  It  is  tlierefore  necessary  to  establish  continuous  aspiration  of  the 
urine.  Kelly  lias  dexised  an  as])irator  consisting  of  a  rubber  bulb  which 
cominunicates  hy  means  of  a  rulihei-  tube  with  a  small  silver  ])erforated 


224 


CYSTOSCOPY   AXD    URETHROSCOPY 


ball.  This  aspirator  is  introduced  into  the  cystoscopic  tube,  thus  fur- 
ther narrowing  the  lumen  of  the  tube  and  also  necessitating  the  pres- 
ence of  an  assistant.  «>► 

In  the  belief  that  such  a  sjDecial  instrument  is  not  necessary,  I  have 


Fig.   144. — Water   horn    (faucet). 

constructed  a  small  gutter  or  trough  in  the  inferior  Avail  of  my  new 
tube,  through  Avliich  the  aspiration  of  the  urine  takes  place.  The. ori- 
fice of  this  channel  reaches  doA\Ti  to  the  vesical  end  of  the  cystoscope; 
externalh^  it  ends  in  a  metallic  tube  to  which  is  attached  a  rubber  tube 
(Fig.  145).     The  latter  empties  into  a  closed  jar  controlled  by  two 


Fig.   145. — I.,uj's'    female   cystoscope,   with   its   straight   obturator. 

stop  cocks  in  which  a  vacuum  can  be  created.  The  vacuum  can  be 
established  by  a  Potain  aspirator,  but  this  is  not  to  be  recommended 
because  the  vacuum  thus  created  is  not  sufficient  for  the  purpose.  It 
is  much  more  practical  and  even  essential  to  use  a  Avater  horn  attached 
to  a  faucet  (Fig.  144).    On  opening  the  faucet  a  A^acuum  is  produced  in 


Fig.   146. — L,uys'  male   cystoscope,   with   its   elbowed   obturator. 


the  jar  and  the  urine  is  thus  aspirated.  The  manipulation  is  A^ery  sim- 
ple; asjDiration  is  rapid  and  i^erfect,  cleansing  the  mucosa  not  only  of 
urine,  but  also  of  any  mucus  or  blood  clots  Avhicli  might  be  j)resent. 


DIRECT  VISION'  cssroscopv 


225 


This  coiislniil  cNacualioii  of  iiriiic  is  iii(lis|i('iis;il)l('  to  clc-ir  \isioii  and 
tlie  exatniiialioii  can  tliiis  he  iiiadf  witlioiil  inlcri'iiplio!!. 

Tlie  water  pressure  in  Ww.  iaucet  should  l)e  of  sufficient  strenr;,th; 
and  the  Tu])l)er  tuhin.i;'  shouhl  l)e  sufficiently  firm  so  that  it  Avill  not  col- 
lapse when  the  \acuuni  is  estahlishcd  in  the  jar.  The  latter  has  a  two- 
hi'aiiched  glass  luhc  Icadiiiu,'  into  it.  To  one  is  attach('(l  a  ruWhci-  luhe 
which  is  coiniected  with  the  water  faucet,  and  to  the  other  is  connected 
the  tube  which  receives  the  urine  from  the  bladder  thi'ouah  the  cysto- 
seope. 

4.  Magnification  of  the  Image. — ^lagnification  is  obtained  by  the  ad- 
dition of  a  mova])le  lens  having  a  focal  length  corresponding  to  the 
length  of  the  cystoscopic  tube.    This  lens  may  be  applied  at  the  external 


Fig.    147. — Uandle   of   the   direct  vision   cystoscope,   with   its   movable   lens;    it   is   the   same   as  the   handle   of 

the  urethroscope. 

orifice  of  the  tube  without  in  any  way  interfering  with  the  introduction 
of  instruments;  when  not  in  nse,  it  can  be  rotateti  out  of  the  way  (Fig. 
147). 


DESCRIPTION  OF  THE  DIRECT  VISION  CYSTOSCOPE  (LUYS) 

This  instrument  consists  essentially  of  a  metallic  tube,  18  cm.  long 
for  the  male,  and  10  cm.  long  for  the  female.  I  liave  adopted  this  length 
for  the  female  cystoscope,  allowing  four  centimeters  for  the  vulvar 
distance,  two  centimeters  for  the  urethra,  and  the  remaining  four  cen- 
timeters for  llic  bhidder  proper.  The  caliber  of  tlie  lube  selected  varies 
according  to  the  caliber  of  the  uretln-a,  which,  according  to  Kelly, 
varies  from  six  millimeters  (minimum)  to  twenty  millimeters  (maxi- 
nmm).  According  to  Simon,  the  maximuni  (lilalability  of  tlie  female 
urethra  is  a  little  more  than  29  centimeters. 

It  is  usuallv  sufficient  to  use  a  Xo.  2f)  Charriere  tube,  but  if  the 


226 


CYSTOSCOPY   AND   UEETHBOSCOPY 


urethra  is  normal,  a  larger  tube  may  be  used,  as  it  will  provide  a  mucli 
larger  field  of  vision.  As  often  as  circumstances  permit,  I  i^se  a  29.5 
Cliarriere  tube  in  either  sex. 

As  previously  mentioned,  there  is  a  ver}^  minute  channel  or  gut- 


Fig.   148. — Collin's  group  of  batteries. 

ter  in  the  floor  of  the  urethroscope ;  this  does  not  impinge  on  the  lumen 
of  the  tube.  It  is  connected  with  the  vacuum  jar  by  means  of  a  rubber 
tube.     There  is  another  little  gutter  on  the  upi^er  wall,  parallel  Avitli 


Fig.   149. — I<uys'  direct  vision  cystoscope  for  the  female. 

the  low^er,  for  the  lami^  carrier,  so  as  not  to  obstruct  the  tube's  lumen. 

The  tube  is  introduced  with  the  aid  of  a  straight  obturator  (Fig. 

145)  for  the  female  cystoscope,  and  an  elbowed  obturator  for  the  male 


DESCr.lPTloX    Ol'    l)ll;i:('T    VISlOX    CVSTOSCOPH 


227 


(Fi.i;'.  ^4(')).  ''I'lic  ('11)()\v(m1  porlion  projccls  hcyotid  llic  liilx'  into  Hie 
])la<l(l('i'  I'oi-  ilircc  ('(MiliiiK'tcrs,  aiid  can  he  sli'ai^^lilciKMl  oi-  IxmiI  l)y 
iiicatis  of  a  sci'cw.  'I'lic  bend  in  ilic  oMurator  facilitates  llic  inti'oduc- 
Hoii  of  tlic  iiisti-uiiHMit  into  llic  bladdci'.  As  soon  as  it  lias  l)0('n  intro- 
duced, the  obturator  is  straiii,-litene(l  and  witlidi-awii  from  1lic  bladder, 
llluniination  is  furnished  by  a  miniature  electric  lamp,  described  above 
(page  40).  It  is  extremely  brilliant  considering  its  small  size,  and  ab- 
solutely "cold,"  especially  when  ne^^^  Unfortunately,  as  the  lamps 
groAV  old,  they  require  a  greater  current  and  consequently  produce 
more  heat,  which  constitutes  a  decided  disadvantage.    It  is  advisal)lo 


■'//■■ '  I 


Fig.    150. — I,uys'   direct   vision   cystoscope   for  the   male. 


in  actual  practice,  to  use  only  such  lamj)s  as  are  absolutely  cold,  re- 
jecting those  Avliich  show  evidences  of  getting  warm. 

The  lamjD  is  carried  on  a  long  stem  attached  to  the  handle  of  the 
cystoscope.  The  latter  is  provided  with  an  interrupter  and  receives 
the  conducting  wires  of  the  electric  current.  It  carries  in  addition, 
a  demountable  magnifying  lens,  situated  in  a  movable  frame.  Its 
focal  length  corresponds  to  the  length  of  the  tube.  The  lens,  as  already 
mentioned  (page  45),  may  l)e  constructed  with  an  aperture  in  its  cen- 
ter, thus  making  it  unnecessary  to  move  it  aside  when  making  local 
applications  to  the  vesical  mucosa. 

The  handle  is  firmly  fastened  to  the  tube  l)y  means  of  a  screw. 
The  source  of  the  electricity  varies  according  to  the  i)lace  where  the 
instrument  is  used.  Undoubtedly  the  street  current  is  the  most  de- 
sirable and  practical,  but  the  high  Noltage  must  be  reduced  by  the  em- 
ployment of  a  rheostat  (Figs.  4G  and  47). 


PLATE  XIV 

Fig.  1. — Chronic  cystitis.  Aspect  of  the  fundus  resembling  grains  of  sand. 
In  front,  the  interureteral  ligament  is  seen;  posteriorly,  on  another 
plane,  chronic  cystitis  is  visilile  in  the  form  of  grains  of  sand,  and 
still  further  back,  healthy  mucosa. 

Fig.  2. — Vesical  herpes.  The  right  ureteral  orifice  is  seen,  and  near  it, 
disseminated  herpetic  plaques,  transparent,  and  resembling  bubbles. 


Fis.  1. 


TICCIINIC    ()!•■    DIKKCT    VISION    (•^■ST()S(:()PY 


1220 


TECHNIC  OF  DIRECT  VISION  CYSTOSCOPY 

Preparation  of  the  Instruments. — Th^i  iii.slruinoiil.s  sliould  Ix;  steril- 
ized. The  eyslos('()])i('  luhe  and  its  obturator  can  l)e  l)oiled  in  water; 
tlie  lamps  are  sterilized  in  a  trioxynietliylene  (paraform,  formalin) 
sterilizer.    The  vacuum  apparatus  is  tested  to  see  that  it  works  prop- 


Fig.   151. — Tampon   of  cotton   niounteil   on   a  wooden   apjilicator. 

erl\-;  likewise  the  lamps  and  the  electric  current.  AYooden  applicators 
capped  with  sterile  cotton  should  be  within  easy  reach  on  a  tahle  (Fig. 
151). 

Preparation  of  the  Patient. — The  patient  is  undressed  except  for 
his  shirts.    The  bladder  is  washed  with  a  catheter,  syringe  or  irrigator, 


Fig.    152. — Tabic    specially    Ijuill    accordi'.'g    to    my    directions    for    urinary    examination,    horizontal    iiosition. 

until  llie  washings  come  out  (piite  eleai-;  llie  bladder  is  now  emi)tied 
comjjletely.  The  jiatient  is  jilaced  in  the  ])artial  Trendelenburg  posi- 
tion, the  buttocks  resting  on  the  edge  of  the  table.  Adjustable  shoulder 
supports  help  to  maintain  the  patient  in  the  i^roper  position.  The  feet 
rest  in  the  stirrups  witli  the  legs  ^^('ll  separated.  For  e.Kainiuation  of 
the  bladder  fundus  or  for  ealhelerizalioii  of  the  ureters,  the  buttocks 


230 


CYSTOSCOPY    AND    URETHROSCOPY 


should  not  be  elevated  too  much.  On  the  other  hand,  the  roof  of  the 
bladder  is  better  inspected  Avlien  the  thighs  are  well  elevate^.  The 
head  may  rest  on  a  little  j)illow. 

In  acute  painful  cystitis  or  in  sensitive  patients,  a  local  anesthetic 
should  be  employed.  Ten  to  20  c.c.  of  a  sterile  1  per  cent  solution  of 
stovaine  may  be  used.  Bransford  Lewis,  of  St.  Louis,  deposits  little 
tablets  containing  5  to  10  per  cent  of  cocaine  into  the  posterior  urethra 
by  means  of  his  tablet  depositor.    According  to  this  author,  anesthesia 


Fig.    153. — Table    specially    built   according   to    my    directions   for    examination    with   direct   vision    cystoscope. 

of  the  bladder  can  be  jDroduced  more  easily  by  this  ingenious  method 
than  by  any  other. 

Half  an  hour  before  the  examination,  a  solution  containing  twelve 
drops  of  laudanum  and  one  or  two  grams  of  antipyrin  may  be  de- 
posited in  the  bladder  for  anesthesia.  In  extremely  painful  cases,  an- 
esthesia may  be  produced  by  the  subcutaneous  injection  of  scopolamine, 
according  to  the  technic  described  by  Terrier  ;^  also  by  an  injection  of 
morphine,  or  in  extreme  cases,  through  the  use  of  a  general  anesthetic. 


REEEREI^CE 

iTenicr:     Bull,  de  Soc.  de  Chir.,  1905,  p.  347. 


TICCIIXIC    Ol'     IHUKC'I'    VIS  I  OX    CYSTOSCOPY  _.>l 

Operative  Technic 

Introduction  of  the  Cystoscope  in  the  Female. — If  a  i-atlicr  lai-ft'c 
eysloscopic  liihc  has  Ix'cii  clioscii,  ;i  Xo.  2!)..")  For  cxaiiipN^  it  is  well  to 
dilate  tlic  urcllii'a  lii'sl,  cillici-  witli  Kcilly's  meatus  dilator  or  l)\'  ilio 
l^assage  of  Jlegar's  rounds,  No.s.  6,  7,  8,  and  1).  This  facilitates  tlie  in- 
troduction of  the  cystoscopic  tube.  If  the  meatus  is  somewliat  nari'ow 
and  sensitive,  it  is  well  to  insert  into  the  urethra,  l)efore  dilatation,  a 
cotton  tani])()n  soaked  in  a  5  or  10  per  cent  solution  of  stovn.ine;  this 
is  liii;lilv  recoiiuueuded  hv  Kelly,  and  f^'ives  excellent  results. 


Fig.   154. — Examination    of   the   bladder   with    the    direct   vision    cystoscope. 

The  cystoscope  having  Ijeen  sterilized  and  lubricated  with  sterile 
glycerin,  is  gently  inserted  into  the  bladder.  The  obturator  is  with- 
drawn and  when  the  table  is  elevated,  it  is  seen  that  the  bladder  be- 
comes filled  with  aii'. 

In  the  Male:  In  llie  male,  it  is  al)solutely  necessary  to  have  a  canal 
free  from  stricture,  and  stretched  in  advance  l)y  the  passage  of  sounds 
up  to  28-29,  if  possible.  If  this  jn-ecaution  has  been  taken,  the  intro- 
duction of  the  cystoscopic  lube  ])i-("S(Mits  no  (iilliculties.  The  instrument 
is  inti'oduced  into  the  hiaddcr  with  the  elbowed  obturator.  The  screw 
controlling  the  handle  is  released,  thus  straightening  the  obturator,  and 


^32 


CYSTOSCOPY   AND    URETHROSCOPY 


tlie  latter  is  withdrawn  from  tlie  tube.     The  operative  teclmic  is  now 
tlie  same  in  both  sexes. 

The  cystoscope  having  been  inserted,  the  aspirator  is  connected, 
so  that  the  bladder  will  be  kept  dry  thronghout  the  examination.  Oc- 
casionally Avhen  the  bladder  is  not  well  dilated,  the  mncosa  may  pro- 
trude into  the  interior  of  the  tube.  It  is  then  necessary  to  interrupt 
the  aspiration  until  a  little  fluid  has  accumulated  in  the  bladder.  The 
handle  of  the  cystoscope  is  now  fastened  by  a  screw  and  the  current 
turned  on. 


Fig.    155. — K-xamination   of   the   bladder. 


Exact   position   of   the   direct   vision   cystoscope   in   the   female. 


The  bladder  is  seen  splendidly  illuminated,  so  that  every  detail 
can  be  recognized.  The  vesical  extremity  of  the  cystoscopic  tube  moves 
freely  in  the  bladder  and  can  be  easily  manipulated  in  all  directions, 
because  of  the  distention  brought  about  by  the  inclined  position. 

Examination  of  the  bladder  floor  is  quite  simple.  By  raising  the 
handle  of  the  instrument,  the  vesical  end  is  depressed  correspond- 
ingly, thus  bringing  the  trigone  within  view  easily.  The  roof  is  ex- 
amined by  lowering  the  handle  of  the  cystoscope  and  thus  elevating- 
its  vesical  extremity.  It  is  advisable  to  make  gentle  pressure  on  the 
abdominal  wall  over  the  bladder;  the  entire  bladder  roof  then  comes 
into  view  in  the  cystoscoiDic  tube,  and  no  jDortion  of  the  vesical  mucosa 
can  escape  observation. 


'i'i':cii  NIC  oi'   i)ii;i:ci'   \  isiox  cn'stoscoim' 


233 


Ai'.X()i;.MAi.  Cases 

III  (liiccl  \isi()ii  cysioscopy,  pdl)'  <lir(iciiU  ics  iii;i\'  he  ciiccjiiiitcrcd, 
]).-ni  iciilarly  li>'  ;i  iioxicc,  llic  two  inosl   iinptniaiil    liciiii;'  llic  ("ollowjiig: 

1.  llic  hhuhlcf  (Iocs  iiol  dildlc  I iillij  undar  the  influence  of  the  in- 
rliiicfl  po.^lliou.     This  mn\'  he  due  to  several  causes:    (a)  The  patient 


I'ig.    156. — If    the   bladder    does    not    dilate    well    in    the    inelined    position,    an    assistant    elevates    the    abdom- 
inal  wall,   thns   facilitating   the   stretehing   of   the   bladder. 

may  he  too  stout,  and  tlie  al)doininal  fat  may  prevent  tlie  bladder  from 
distending  itself  and  tlms  becoming  filled  Avitli  air.  Tt  is  tlien  neees- 
sarj'' to  still  fui'tlier  elevate  tlie  pelvis.  W'lieii  Ihe  iiicliiied  iio^ilion  lias 
been  ])uslie(l  to  its  limil,  and  if  the  hhidder  still  does  not  distend  it- 
self, the  followiiiu'  expedient  iiia>-  he  employed,  es])eeially  when  the 
abdominal  wall  is  llahhy:    An  assistant  grasps  the  abdominal  wall  as 


234  CYSTOSCOPY   AND    URETHROSCOPY 

near  tlie  pubis  as  jDossible,  with  both  hands,  raising  up  as  much  of  the 
wall  as  he  can  seize  (Fig.  156).  This  maneuver  will  very  often  succeed 
in  causing  distention  of  the  bladder  and  a  jDerfect  view  of  tlie  entire 
vesical  cavity  is  thus  obtained.  If,  however,  the  result  is  still  unsat- 
isfactory, the  genui^ectoral  jDosture  must  be  resorted  to.  (b)  The  pa- 
tient may  be  thin,  but  resists  and  contracts  the  abdominal  muscles 
spasmodically.  This  is  because  the  patient  is  nervous,  and  requires 
a  local  anesthetic  before  relaxation  is  secured. 

2.  Tlie  vesical  mucosa  may  bleed  profusely.  This  renders  a  clear 
view  extremely  difficult  and  nothing  but  blood  can  be  seen.  The  ac- 
tion of  the  aspirator  is  insufficient  to  take  up  a  large  quantity  of  blood, 
and  even  if  it  took  jxp  all  the  fresh  bleeding,  it  would  still  be  unable  to 
remove  the  coat  of  blood  which  covers  the  fungosities  in  the  bladder. 
In  such  cases  it  is  necessary  to  swab  the  mucosa  with  little  tampons  of 
dry  cotton.  Occasionally  however,  the  mere  contact  of  these  swabs 
actually  increases  the  bleeding  of  the  mucosa.  The  only  thing  to  do  is 
to  use  a  1 :1000  solution  of  adrenalin.  Tampons  soaked  Avith  this  solu- 
tion are  brought  into  contact  with  the  bleeding  points  and  the  hemor- 
rhage ceases. 

ADVANTAGES  OF  DIRECT  VISION  CYSTOSCOPY 
IN  EXAMINATION  OF  THE  BLADDER 

The  direct  examination  of  the  vesical  mucosa  by  the  simj)le  cysto- 
scopic  tube  offers  many  advantages  over  the  indirect  (iDrismatic) 
method.  In  the  normal  bladder,  the  two  i3rincij)al  advantages  are  the 
following : 

1.  The  Direct  View. — With  direct  vision  the  various  regions  exam- 
ined are  seen  just  as  they  really  are,  in  their  normal  position,  form, 
and  situation,  and  are  not  deformed  in  any  manner.  The  personal  in- 
terpretation does  not  enter  into  consideration  and  no  matter  how  inex- 
perienced in  cystoscopy  the  observers  may  be,  they  all  see  the  pictures 
alike,  because  the  image  is  not  deformed  or  inverted.  This  is  a  de- 
cided advantage,  especially  in  determining  the  volume  of  a  stone  or  of 
a  vesical  tumor.  In  fact,  in  order  to  see  well  with  the  indirect  cysto- 
scope,  it  is  necessary  to  keep  the  instrument  at  a  certain  distance  from 
the  object.  Inasmuch  as  it  is  difficult  to  say  what  this  distance  should 
be,  even  a  well-practiced  eye  may  make  serious  errors  in  determining 
the  actual  size  of  foreign  bodies  in  the  bladder. 

In  making  a  full  view  examination,  the  direct  vision  cystoscope 
also  has  a  decided  advantage  over  the  indirect.  By  inclining  the  tube 
so  that  its  long  axis  is  almost  parallel  with  the  surface  of  the  mucosa 


ADVANTA(JES    OF    DIItECT    VISION    CYSTOSCOPY  235 

to  he  cxainiiKMl,  a  scries  uT  cliau^i'S  of  the  iiiiicosa  can  l)c  ^ccii  in  pro- 
lilc  which  woiihl  escape  iinol)servo(l  when  the  same  mucosa  is  looked 
al  in  Tull  \ie\v.  I  ha\<'  thus  heen  enal»hMl  to  ohserve  and  make  sketclies 
ill  miiuerous  cases  ol*  cliroiiic  cystitis,  of  alterations  consisting-  of  little 
elevations  in  the  form  of  grains  of  sand  wliicli  can  not  be  seen  well 
with  the  indirect  cystoscope. 

2.  Normal  Coloring  of  the  Mucosa. — Tlie  necessily  of  liilini;'  the 
l)la(i(U'r  witli  water  or  air,  in  oi'der  to  obtain  a  good  view  in  indirect 
cystosco])y,  causes  a  certain  amount  of  distention  which  in  tuiii,  pro- 
duces a  condition  of  anemia.  The  real  color  of  the  nuicosa  is  therefore 
not  seen.  On  the  other  hand,  in  direct  vision  cystoscopy,  the  hla<lder 
is  distended  without  force  and  the  natural  tints  of  the  nmcosa  are  seen 
just  as  they  are  in  reality. 

3.  Possibility  of  Examination  in  Contracted  Bladder.— The  di- 
rect vision  cystoscope  permits  the  examination  of  inflamed  l)ladders 
which  have  not  a  sufficiently  large  capacity  to  permit  their  distention 
by  the  quantity  of  fluid  required  for  indirect  cystoscopy.  It  is  well 
known  that  ]:)rismatic  (indirect)  cystoscopy  is  well  nigh  impossil)le 
when  the  vesical  capacity  is  less  than  60  c.c,  and  gives  results  Avhich 
are  practically  nil.  Such  instances  are  not  at  all  rare;  especially  is 
this  true  when  the  ureters  are  to  be  eatheterized.  I  shall  again  con- 
sider this  later  on. 

4.  Possibility  of  Examination  in  Hematuria  and  Pyuria.— In  hema- 
turia and  pyuria,  when  examination  is  almost  impossible  in  spite  of  the 
most  copious  irrigations,  direct  vision  cystoscopy  has  a  distinct  ad- 
vantage over  the  indirect  method;  only  by  this  method,  can  we  obtain 
the  necessary  and  precise  information  in  cases  of  profuse  hemorrhage 
which  would  obstruct  the  field  of  vision  in  the  indirect  vision  cysto- 
scope. In  this  manner,  errors  which  are  as  considerable  as  they  are 
to  be  regretted,  can  be  avoided. 

An  especially  interesting  case  observed  by  me,  is  that  of  a  woman 
aged  forty  years,  whom  I  treated  in  1907.  She  was  a  patient  of  Uoutier, 
who  had  referred  her  to  me  because  of  hematuria,  and  he  wanted  my 
cystoscopic  opinion.  Another  specialist,  who  was  previously  consulted, 
had  declared  after  an  indirect  cystoscopy,  that  the  patient  did  not  have 
a  tumor  of  the  bhuhU'r,  but  that  slie  ha<l  a  cyst  in  1lie  lower  extrem- 
ity of  the  left  ureter!  AVIieii  1  examined  her,  she  liad  well-marked 
henuituria.  As  soon  as  the  indirect  cystoscope  was  inserted  into  the 
bladder,  whirlpools  of  blood  prevented  distinct  vision  and  made  the 
examination  impossible.  I  then  used  my  direct  cystoscope  and  was 
enabled  to  make  a  ]iositive  diagnosis  of  a  large  tumor  of  the  bladder 


236  CYSTOSCOPY   AND    URETHROSCOPY 

situated  in  the  left  lateral  portion  of  the  fundus.  In  view  of  this  diag- 
nosis, Eoutier  had  his  patient  enter  the  sanitarium  two  days  Igter. 

On  opening  the  bladder,  a  tumor  the  size  of  a  pigeon's  egg  Avas 
removed,  and  the  histologic  examination,  made  in  the  laboratory  of 
Necker  by  Herrenschmidt,  showed  that  the  growth  Avas  a  hbroma.* 

5.  Possibility  of  Examination  in  Cases  of  Perforation  or  Vaginal 
Fistula. — The  direct  vision  cystoscope  is  the  only  instrument  for  the 
examination  of  a  bladder  with  a  fistula;  such  for  example,  as  a  vesico- 
vaginal fistula.  In  these  cases,  it  is  manifestly  impossible  to  distend 
the  bladder  Avith  a  fluid  Avliich  it  can  not  hold,  and  the  only  method  to 
be  employed  is  certainly  direct  Adsion  cystoscopy. 

It  is  superfluous  to  insist  on  the  importance  of  the  exact  knoA\d- 
edge  of  the  seat  of  the  A^esical  ]3erforation  in  A^esicoA^aginal  fistula. 
With  the  aid  of  ni}^  direct  Adsion  cystoscope,  a  probe  can  be  introduced 
into  the  fistula  Avliich  penetrates  the  A^agina  and  indicates  the  direction 
of  the  fistula  in  the  clearest  manner.  The  serAdces  AAdiich  this  method 
may  render  in  such  a  case,  are  Avell  sIioaa^u  by  the  tAvo  folloAving  ob- 
serA^ations  by  Ferron:^ 

"Ferron  examined  a  patient  Avith  a  A^esicoA^aginal  fistula.  A  probe 
AA^^as  introduced  into  the  fistula  through  the  A^agina;  this  Avas  folloAved 
by  direct  Adsion  cystoscopy.  It  shoAved  that  the  fistulous  orifice  w^as 
very  near  the  ureteral  orifice.  On  operation,  the  fistula  Avas  sutured, 
at  the  same  time  avoiding  closure  of  the  ureteral  meatus. 

''In  another  case,  a  mistake  in  diagnosis  Avas  rectified  by  direct 
vision  cystoscopy.  A  Avoman  liaAdng  undergone  total  hysterectomy 
was  emitting  urine  through  the  A^agina.  The  clinical  diagnosis  Avas 
vesicovaginal  fistula.  Then  Ferron  employed  direct  vision  cystoscopy; 
the  bladder  seemed  perfectly  normal,  and  A^d^le  catheterization  of  the 
left  ureter  Avas  easy  and  produced  urine,  it  Avas  impossible  to  pass  even 
a  filiform  into  the  right  ureteral  orifice.  The  diagnosis  Avas  tlierefore 
changed  to  ureteroA^aginal  fistula." 

REFEEEI^CE 
iFerron:     lu  These  de  Chardon,  la  Cystoscopie  a  A-ision  diiecte.  Bordeaux,  1912,  -p-  47. 

6.  Possibility  of  Examination  in  Urethrovesicovaginal  Fistula.^ — 

If  A'^esicoA^aginal  fistula?  are  not  relatiA^ely  rare  in  Avomen,  that  can  not 
be  said  to  ])e  true  of  cases  Avhicli  are  complicated  Avith  another  com- 
munication betAveen  the  bladder  and  the  urethra,  in  the  form  of  an 
abnormal  channel  j)assing  outside  of  the  A^esical  neck  from  the  blad- 

*The   specimen   is   to   be    found   in    our   private    collection. 


ADVANTACKS    OF    DIKKCT    VISION    CYSTOSCOPY 


237 


(Icf  to  lln'  ])()sl('ri()f  |)()iil()ii  of  llic  iircllira.  hi  siidi  a  case,  iiicoii- 
liiiciicc  of  urine  scciiis  lo  proceed  IVoiii  1!ie  \-esi('o\-a,i;'iiial  li-liila  alone, 
l)ul   ilie  oilier  vesi('()])araiirel  liial   canal  is  none  1lie  less  an   intereslin.L!; 


Fig.   157. — N'esicovaginal   fistula.     A  catheter  is   introduced  into  the  urethra;   the   opening  of   the   fistula   is 

seen  a  little  below  and  to  the  right. 

anatomieopatliologic  complication  Avliicli  mnst  ho  takcMi  into  consider- 
ation. 

These  nrellirovesicova.ninal  lislula'  liave  ])cen  ol)ser\-e(l  Imt  rarely, 
and  the  cases  oi*  this  kind  met  Avith  in  literature  do  not  reseml)le  the 
one  al)out  to  be  descril)ed,  for  the  urethrocystoscopic  investigations 


238 


CYSTOSCOPY   AND   ITRETHEOSCOPY 


which  coukl  reveal  them  ^ve^e  not  in  current  medical  practice  at  that 
time.  Mv  direct  vision  cystoscope  gives  a  clear  view  of  the  neck  of  the 
bladder  quite  as  well  on  the  vesical  side  as  on  the  urethral,  and  thereby 
facilitates  the  investigations  considerably/ 


Fig.  158.-Determining  the  exact  position  of  the  orifice  of  a  vesicovaginal  fistula  by  means  of  di- 
rect vision  cystoscopy.  A  grooved  director  inserted  into  the  fistula  marks  the  orifice  of  the  fistula  m  tne 
bladder. 

Verneuil  has  called  attention  to  this  subject/^  and  has  reported  sev- 
eral cases  of  fistula  joining  the  neck  of  the  bladder  with  the  urethra; 
he  termed  them  '^irethrovesicovaginal  fistula?."  He  distinguished 
several  groups: 


ADVAKTAdES    Ol'    DinKCT    VISIOX    CYSTOSCOPY 


239 


1.  \'('i'y  loiii;'  lisliihi',  nCrccl  iiii;-  llic  neck  ol'  llic  l)l;iil<l('r  and  o!'  tlic 
ui'dliia  coiisidcrahlx',  and  sliowiiii;'  one  lar,i;'('  ()])('nin;:,'  l)()i-d<'f(Ml  hy  llio 
])liul<kn'  miil  llie  I'eiiuiaiit  of  tlie  urelliia. 

2.  Fistultc  situated  low  down,  A\itli  a  modi  fixation  of  the  ure- 
tliral  patli  or  caliber:*  Verneuil  tlioii;j,ld  lliat  many  cases  reported  as 
obliteration  of  the  canal,  are  rather  deviations,  and  tlial  ol)lil('iation  is 
very  rare.    ITe  cites  two  cases. 

3.  Fistnhi^  situated  low  down,  in  wliich  a  continuous  incontinence 
simulated  a  complete  destruction  of  llic  urethra  and  its  sphincter: 
Tavernier  and  Stephani  have  observed  also  a  vesicovaginal  fistula 
which  involved  the  neck  of  the  bladder  and  the  urethra;  they  suc- 
ceeded in  bringing  about  a  perfect  cure,  with  complete  continence." 


Fig.   159. — Diagram   showing   the   arrangement   of   the   ureterovesicovaginal    fistula. 

A  monograph  Juis  recently  appeared  on  this  sul)ject,  l)y  Piontik, 
of  Pesia  {Ueber  Blasen-Cervixfisteln,  Charlottenlnirg,  1909).  The  case 
which  is  the  basis  of  this  report,  is  the  following: 

Mme.  W.  L.,  aftcd  twenty-nine,  was  sent  on  Felnuary  3,  1911,  to  the  Broca  Hospital, 
in  the  service  of  Pozzi,  complaining  of  constant  enuresis.  Six  months  previously  she  had 
Ijcen  delivered  of  a  child  with  forceps,  at  the  Maternite;  half  an  hour  later,  incontinence  set 
in;  the  condition  was  unchanged  whether  she  was  lying  in  bed  or  up  and  about. 

She  went  first  to  tlie  Beaujou  Hospital,  where  she  was  operated  upon  on  October  12, 
1910,  but  without  any  iiii|iiiivemcnt  whatever.  On  entering  Broca  Hospital,  she  presented  a 
marked  erytlicma  on  the  inner  surface  of  tlie  thighs,  due  to  the  constant  involuntary  flow 
of  urine. 

On    examinatifin    it    w;is    found    thnt    the    vesical    cajiacity    was    about    200    c.c.      Al)Ove 


PLATE  XV 

Fig.  1. — Vesical  leucoplalia.  This  condition,  observed  during  the  course  of 
a  very  marked  cystitis,  is  characterized  by  the  pale  plaques  of  cystitis 
which  contrast  Tvitli  the  strikingly  inflammatory  red  of  the  rest  of  the 
bladder. 

Fig.  2. — Chronic  cystitis.    Mosaic  aspect. 


Fig.  1. 


Fig.  2. 

PLATE  XV 


ADVANTACKS    Ol'    DIIIIUT    \ISI()N    CVSTOSCOPY  241 

this  (|ii,'iiit  ity  (lie  injci-lcil  lliii.l  cscnijn!  Iiv  llir  v;i;iiii;i.  I  '  i  d  li  i;il  rii(|(,sc(i]iy  showed  lliiit 
I  he  ciiiiiil  neck  WHS  ilisliiilcil.  A  I11I1C  (if  my  diicct  vision  cysloscopo  wsis  (djstniftpd  ;it  tiic 
l.hiildci  neck  :iiid  cnnld  mil  pciiil  nil  c  riiilhrr.  it  wris  imjiossililp  to  introducn  tlu!  iiislrunu-nt 
ildn  lllr  liliiddci'  unless  1  lie  exticiiiily  n  I'  the  i  list  liniieiil  \v;is  luriied  olili(|uely  1111(1  rlilTCtcd 
under  cniitrnl  (d'  the  eye.  'I'he  ('iHi()Sco|iic  exaiiii  n;it  ioii  slioweii  lliat  on  tlic  rigiit  side  of  the 
lihidder  neck  ;in  1  exierniii  (i>  it,  thero  was  a  distinct  oiififp  witli  edematous  edges.  A  ureteral 
ciitiuMor  No.  (i,  was  iidroduced  into  this  orifice;  it  ])assc'd  tlio  right  lateral  portion  of  the 
vesical  neck,  rounded  it  and  entered  the  bladder  after  a  passage  of  from  two  or  three  centi- 
meters (Plate  XIII,  Fig.  (i).  This  was  therefore  a  real  urethral  fistula.  Examination  of 
the  ureteral  orifices  revealed  that  they  were  normal,  normally  locatoil  and  could  be  easily 
catheterized. 

In  Sims'  ]iosition  with  the  speculum,  a  vesicovaginal  fistula  about  the  size  of  a  franc 
\2'>  cent  piece  I  was  seen  at  the  neck  (if  llie  bladder  and  alniosl  luiichin-  il.  Tliif;  fistula 
took  on  the  apjieaiance  id'  a  cleft,  the  anterior  edge  of  the  orifice  overlapping  the  posterior. 

To  sum  u[i  then,  there  existed  in  the  vesicovaginal  partition  a  fistulous  passage,  bi- 
furcated from  a  single  orifice:  One  passage,  a  large  one,  extended  from  the  bladder  to  the 
vagina;  a  second  passage,  smaller,  passed  from  the  bladder  to  the  urethra,  and  extended 
around  and  outside  of  the  bladder  neck  (see  Fig.  159).  The  incontinence  seemed  to  be 
(iuc  to  the  first  of  these  passages,  and  was  made  the  object  of  surgical  intervention.  The 
radical  cure  of  the  vesicovaginal  fistula  was  effected  by  operation,  on  March  4,  1911,  by 
Pozzi. 

The  edges  of  the  fistula  were  transfixed  by  retention  sutures  of  silver  wire,  the  fistula 
well  exposed  and  the  edges  excised.  Excision  was  difficult  because  of  the  proximity  of  the 
jieck  of  the  bladder.  To  avoid  traction  on  the  upper  edge,  a  large  transverse  incision  was 
made  in  front  of  the  neck  of  the  uterus,  which  allowed  the  union  of  the  edge  to  the  fistula 
and  thus  gave  a  large  raw  surface.  The  fistula  was  first  obliterated  with  chromic  gut.  The 
closure  of  the  fistula  was  then  completed  by  some  deep  silver  sutures  which  passed  into  the 
uterine  neck.  Finally,  perfect  apposition  of  the  wound  was  secured  hx  superficial  silver 
sutures.     A  permanent   catheter  was  passed  into   the  Ijladder. 

The  postoperative  history  was  without  incident.  On  March  17  the  sutures  were  re- 
moved; on  March  24  the  catheter  was  withdrawn  and  patient  sat  up.  The  operative  result 
was  perfect,  for  she  regained  complete  urinary  control,  whether  reclining  or  up  and  about. 

On  March  31,  1911,  endoscopy  showed  that  the  above  described  anatomic  conditions  at 
the  bladder  neck  remained  unchanged.  The  same  orifice  on  the  right  side  of  the  bladder 
neck  still  permitted  the  introduction  of  a  ureteral  catheter  which  passed  easily  into  the 
bladder.  But  this  did  not  at  all  interfere  with  the  bladder  function,  the  bladder  remaining 
(inite  water-tight,  and  urination  being  performed  under  normal  conditions  which  required 
no  further  therapeutic  interference.  The  patient  left  tlie  hosjiital,  and  when  seen  seven 
itKMiths  later    (October,.  1911)   she  was  in  excellent  condition. 

7.  Possibility  of  Examination  with  Pregnancy  or  Abdominal  Tu- 
mors.— It  is  a  well-establisliod  fact  tliat  to  ol)tain  a  distinct  view  witli 
tlie  indirect  vision  cystoscoi^e,  it  is  necessary  to  keep  the  instnniient  at 
a  certain  distance  from  the  object  to  be  examined.  Now,  avIicii  the 
hUidder  is  compressed  through  pregnancy  or  because  of  a  tumor  near 
the  bhidder,  this  mass  makes  it  impossible  to  maintain  the  cystoscopic 
prism  at  a  sufHcicMit  distance  from  the  vesical  mucosa.  Tliis  disadvan- 
tage docs  not  exist  in  dii-ect  \isi()n  cyst<)S('()p^^  Ix'cause  tlie  iiist  ruiiieiit 
can  he  hfought  to  the  wvy  wall  of  the  hhuhler,  and  aUows  the  smalh\st 
(h'tail   to  he  studied.     Isxaitiiiiat ion  of  the  hhuhh'i'  in  ])regnancy  Avitli 


242  CYSTOSCOPY  ajstd  urethroscopy 

the  direct  vision  cystoscope,  lias  been  studied  in  collaboration  with 
Bar;  a  report  of  this  work  is  published  further  on  (see  page  ^48). 

8.  Extraction  of  Foreign  Bodies. — Extraction  of  foreign  bodies  is 
extremely  easy  with  the  direct  vision  cystoscope ;  this  subject  will  also 
be  thoroughly  discussed  later  on. 

9.  Treatment  of  Cystitis. — The  treatment  of  cystitis  with  the  di- 
rect vision  cystoscope  gives  results  that  are  absolutely  remarkable,- 
and  will  be  discussed  at  greater  length. 

10.  Treatment  of  Bladder  Tumors.— The  treatment  of  bladder  tu- 
mors with  the  direct  vision  cystoscope  produces  radical  cures.  This 
subject  will  likewise  be  discussed  in  subsequent  pages. 

RErEEEISrCES 

iLuys:     Eev.  de  gynec.  et  de  chir.  abd.,  March,  1912,  No.  3. 

-Luys:     ExiDloratiou  de  I'appareil  urinaire,  Paris,  Massou,  1909,  ed.  2,  p.  217. 

2Verneuil:     Chirurgie  rex^aratriee,  p.  932. 

^Verueuil:     Bull,  et  mem.  Soe.  de  chir.  de  Paris,  1875,  p.  322. 

^Tavernier  aud  Stephaui:     Lyon  med.,  Dec,  1909,  p.  1023. 

OBJECTIONS  TO  DIRECT  VISION  CYSTOSCOPY 

1.  Diminution  in  the  Visual  Field. — It  is  undeniably  true  that  the 
visual  field  is  much  more  restricted  in  direct  vision  cystoscojDy  than  in 
the  indirect  system.  However,  this  reduction  is  more  apparent  than 
real.  It  is  quite  true  that  when  the  extremitj^  of  the  cystoscope  is  ap- 
plied directly  to  a  point  of  the  vesical  mucosa,  the  observer's  eye  can 
not  pass  much  beyond  its  limits.  On  the  other  hand,  it  is  equally  true 
that  when  the  cystoscopic  tube  is  kept  at  a  certain  distance  from  the 
surface  to  be  examined,  the  visual  field  becomes  much  more  extensive. 
In  fact,  the  ease  and  rapidity  with  which  the  cystoscopic  tube  can  be 
inanijDulated  in  the  interior  of  the  bladder,  make  i^ossible  a  thorough 
examination  of  the  entire  surface  of  the  mucosa.  Tuffter  has  well  said 
in  this  connection,  ''What  one  sees,  one  sees  very  clearly."^ 

2.  Caliber  of  the  Instruments. — The  instruments  employed  in  di- 
rect vision  cystoscojoy  are  necessarily  larger  in  caliber  than  those  used 
in  the  indirect  method.  The  size  of  the  instruments  used  in  the  female 
is  of  little  moment,  owing  to  the  ease  with  Avliich  the  female  urethra 
can  be  dilated;  in  the  male,  however,  the  question  of  size  of  the  instru- 
ment is  of  considerable  importance.  It  may  be  well  to  remember  how- 
ever, in  this  connection,  that  the  difference  in  caliber  between  the  cysto- 
scope for  ureteral  catheterization  (25  Charriere)  and  my  male  cysto- 
scope (27.5  Charriere)  though  appreciable,  is  nevertheless  not  very 
considerable. 


r)i;.ii:(Ti()X.>^  To  diiikct  visiox  cystoscopy  243 

I).  Unfolding  of  the  Vesical  Wall. — As  lias  alicady  ])oon  stated, 
llic  iiiiroldiii^'  ol'  llic  N'csical  wall  1  li foii.^li  llic  iiidiiKMl  position  some- 
times fails,  in  the  ohcsc,  particnlarly  tJie  maie,  tlius  maixiii;;'  tlic  lilad- 
der  examination  difticnlt  and  sometimes  even  impossible. 

This  faulty  retraction  of  the  al)dominal  wall  is  usually  due  to  al)- 
dominal  plethora,  which  prevents  the  bladder  from  filling  up  with  air, 
in  the  inclined  position.  However,  there  is  a  method  of  overcoming 
tliis  disadvantage,  at  least  up  to  a  certain  point.  It  consists,  as  already 
stated  (see  page  233,  Fig.  156)  in  having  an  assistant  seize  the  ab- 
dominal wall  above  the  pubis,  Avith  both  hands,  thus  forming  a  large 
transverse  fold,  and  exerting  an  upward  pull;  in  this  manner,  the  com- 
])]ete  unfolding  of  the  vesical  wall  is  often  obtained,  esx)ecially  in  very 
stout  women. 

The  inclined  position  is  likewise  accepted  very  poorly  at  times 
by  elderly  patients,  who  are  asthmatic  or  very  stout.  These  conditions 
are  evidently  entirely  unfavorable  for  direct  vision  cystoscopy  and 
nmst  be  considered  as  a  contraindication. 

REFERENCE 
iTufficr:      Bull,   et   mem.   Soc.   de   chir.   de  Paris,   March    7,   1905. 

COMPARATIVE  ROLE  OF  INDIRECT  AND  DIRECT 
VISION  CYSTOSCOPY 

Having  studied  the  comparative  advantages  and  disadvantages  of 
direct  and  indirect  vision  cystoscopy,  it  is  well  now  to  examine  in  de- 
tail the  indications  of  each  method,  and  the  conditions  under  which 
one  or  the  other  is  to  be  preferred.  Above  all,  however,  it  should  be 
stated  that  prismatic  cystoscopy  should  not  l)e  set  up  in  opposition  to 
direct  vision  cystoscopy.  Both  methods  are  useful  and  each  has  its 
respective  indications,  and  it  were  childish  to  attempt  to  estal)lish  a 
rivalry  between  them. 

When  the  condition  of  the  bladder  ensemble  is  to  be  determined 
so  that  a  diagnosis  may  be  made,  it  is  undeniably  wise  to  begin  with 
the  indirect  cystoscope.  This  instrument  gives  an  extensive  visual 
field,  and  a  complete  examination  of  the  bladder  can  be  made  with  it 
in  a  short  time;  and  when  the  patient  hapiDens  to  be  large  and  stout, 
in  whom  the  inclined  position  would  be  particularly  uncomfortable, 
this  instrument  will  l)e  found  pi-eferable  l)y  far. 

But  on  tlie  otiier  liaiid,  when  the  presence  of  blood  or  ])us  in  too 
great  a  quantity  renders  it  impossible  to  obtain  a  sufficiently  trans- 
])arent  medium  even  with  the  aid  of  the  irrigating  cystoscope,  the  di- 


244  CYSTOSCOPY    AXD    URETHROSCOPY 

rect  vision  cystoscope  should  be  resorted  to,  and  it  will  reveal  every 
portion  of  tlie  bladder  despite  severe  bleeding  or  intense  pjairia.  In 
addition,  donbtfnl  jDoints  will  be  cleared  np  and  the  real  size  of  a  tu- 
mor determined  far  better  through  the  direct  and  immediate  view  than 
through  the  jDrism. 

If  a  vesical  tumor  or  a  foreign  body  is  examined  with  both  in- 
struments, the  same  impression  can  not  be  obtained  with  the  indirect 
instrument  as  with  the  direct.  It  is  a  fact,  that  in  order  to  see  well 
with  the  indirect  cystoscope  it  is  necessary  to  keep  at  a  certain  dis- 
tance from  the  object  to  be  observed;  mau}^  bearings  must  be  taken 
in  order  to  be  able  to  examine  all  around  the  tumor,  to  determine  the 
distance  and  the  volume  of  the  tumor  by  this  method.  On  the  other 
hand,  with  the  direct  vision  cystoscope,  the  object  is  seen  directly  as 
it  reall}'  is,  and  its  exact  size  can  be  determined  in  the  most  x^recise 
manner. 

Moreover,  in  numerous  instances,  the  indirect  cystoscope  leaves 
the  oliserver  in  doubt  as  to  the  existence  of  a  calculus  in  the  bladder. 
Indeed,  in  chronic  cystitis,  the  vesical  wall  ma^^  be  altered  to  such  an 
extent,  that  large  masses  of  pus  may  accumulate  in  the  fundus  and 
simulate  a  stone  perfectly.  This  error  can  never  occur  with  the  direct 
vision  cystoscope,  for  it  is  an  easy  matter  to  introduce  a  metallic  stylet 
into  the  cystoscopic  tube  and  thus  obtain  the  metallic  contact  which 
makes  certain  the  diagnosis  of  vesical  calculus.  This  maneuver  is  not 
possible  with  prismatic  cystoscopy.  [AVitli  the  most  modern  operative 
cystoscopes  (indirect),  it  is  just  as  simple  a  matter  to  introduce  a  sty- 
let up  to  the  suspected  stone,  to  obtain  the  metallic  contact.  This  con- 
tact may  often  be  obtained  by  the  cystoscope  itself  coming  in  contact 
with  the  mass  and  eliciting  the  sensation  the  author  refers  to. — Editor.] 

Similarly,  in  studying  certain  inflammatory  changes  of  tlie  vesical 
wall,  encountered  in  mild  cystitis,  much  more  numerous  and  clearer 
details  can  be  seen  with  the  direct  instrument  than  with  the  indirect, 
because  the  tube  of  the  direct  cystoscope  comes  into  direct  contact  with 
the  wall  itself,  and  thus  brings  the  smallest  details  into  view.  jMoreover, 
by  placing  the  tube  in  profile,  a  perfect  view  of  the  minutest  elevations 
and  of  the  slightest  inflammations  of  the  vesical  wall  can  be  obtained; 
these  details  are  important  and  should  never  be  neglected,  for  it  is  due 
to  them  and  to  the  knowledge  of  their  jDresence  that  exact  indications 
for  treatment  can  be  secured. 

Still  further,  when  both  sides  of  the  bladder  neck  are  to  be  ex- 
amined, only  the  direct  cystoscope  should  be  employed.  Indeed,  while 
the  indirect  can  furnish  a  detailed  view  of  the  vesical  aspect  of  the 
bladder  neck,  it  is  absolutely  incapable  of  furnishing  any  information 


ADVANTAGES   OF    DIIIECT    VISION    CYSTOSCOPY  245 

conccriiiiig  lliu  iirL'tliral  side.  (Jii  llie  oilier  Jiaiul,  llio  din-ct  vision 
cystoscope  will  give  a  perfect  view  of  both  aspects.  With  the  cysto- 
scopic  tul)e  still  inside  of  ilie  i)ladder,  its  vesical  extremity  directed 
downward,  the  entire  inferior  wall  of  the  bladder  neck  can  be  fully 
examined;  directing  tlie  end  of  the  tube  upward,  while  tlie  hand  of  an 
assistant  makes  downward  pressure  on  the  al)dominal  wall  above  tlie 
pubis,  the  entire  part  of  the  bladder  neck  is  thoroughly  examined. 
The  examination  having  been  completed,  on  the  bladder  side,  the  cyst- 
oscope is  then  slowly  withdrawn  and  the  bottom  of  the  tube  is  seen 
em]Dty  at  first,  but  gradually  enshrouded  as  it  Avere,  from  periphery  to 
center,  with  the  prostatic  portion  of  the  urethra  (Plate  X,  Fig.  1).  The 
urethra  may  now  be  minutely  examined,  since  under  these  circum- 
stances, the  cystoscope  has  practically  become  a  urethroscope. 

Again,  in  the  matter  of  local  intervention,  within  the  l)ladder,  the 
direct  vision  instrument  is  to  be  preferred.  Whether  it  be  for  the  pur- 
pose of  removing  foreign  bodies,  cauterizing  vesical  tumors,  or  apply- 
ing local  treatment  to  plaques  of  cystitis,  it  is  best  to  have  recourse  to 
the  direct  vision  cystoscope. 

And  as  for  catheterization  of  the  ureters,  we  shall  not  insist  at 
the  present  moment,  for  Ave  shall  discuss  the  indications  Avith  one 
method  or  the  other  in  a  special  chapter  later  on.  NeA^ertheless  Ave  may 
maintain  in  advance  the  superiority  of  the  direct  instrument  Avhich 
permits  catheterization  of  the  ureter  directly,  Avliile  minimizing  the 
chances  of  contaminating  a  health;/  kidney.  The  ureteral  catheter 
passing  directly  from  the  sterilizer  into  the  ureteral  orifice,  can  not 
take  up  any  infectious  germs  en  route  and  thus  contaminate  the  healthy 
kidney  and  ureter. 

Finally,  as  Ave  shall  noAv  see,  the  direct  vicAv  cystoscope  enjoys  a 
Avell-marked  superiority  in  the  examination  of  the  bladder  during 
pregnancy. 

Note:  The  editor  has  recpiested  Dr.  William  F.  Braasch,  Avho  is 
one  of  the  foremost  American  adA^ocates  of  direct  cystoscopy,  to  state 
briefly  the  American  vieAvpoint  on  this  subject.  His  contribution 
foUoAvs: 

DIRECT  CYSTOSCOPY 

By  W.  F.  Bkaascii,  M.D. 

''The  direct  cystoscope  has  been  A'ariously  employed  in  the  cysto- 
scopic  past.  Foremost  among  the  list  of  adherents  to  the  direct  method 
Ave  find  the  name  of  HoAvard  Kelly.^  His  well-knoAvn  methods  need 
no  further  description,  and  today  they  are  still  widely  employed.    His 


246  CYSTOSCOPY   AND    URETHROSCOPY 

metliod  has  not,  however,  received  universal  acceptance  for  several 
reasons;  namety,  (1)  the  preponderance  of  lens  sentiment^  (2)  the 
awkward  position  and  exposure  of  the  patient,  particularly  if  anes- 
thetic he  given;  (3)  the  inahility  to  employ  the  method  in  the  male. 
The  credit  for  presenting  the  first  direct  cystoscope  of  the  modern 
type  should  be  given  to  Bransford  Lewis.-  His  instrument  permitted 
the  dorsal  position  use  in  the  male  and  included  catheterizing  tubes.' 
Instead  of  relying  on  atmospheric  pressure  to  distend  the  bladder,  as 
in  the  Kelly  method,  he  employed  an  air  pump  Avitli  a  retaining  win- 
dow. Direct  air  cystoscopes,  similar  to  that  of  Bransford  I^ewis,  ap- 
peared in  rapid  succession,  Koch,  Belfield,  Snell,  Eisner,^  Luys,*  etc. 
These  instruments  did  not  receive  widespread  employment  largely  be- 
cause of  the  awkwardness  and  pain  caused  by  air  distention  so  em- 
ployed, and  by  the  general  recognition  that  Avater  was  the  better  bladder 
medium  in  cystoscopy.  The  emxDloyment  of  water  in  this  type  of  air 
cystoscoi)e  is  responsible  for  its  survival.  The  late  M.  C.  Millet  of  the 
Mayo  Clinic,  was  the  first  to  demonstrate  the  value  of  this  method. 
He  was  among  the  first  to  emi^loy  the  direct  vieAV  air  cystoscope,  and 
after  finding  the  use  of  air  so  often  unsatisfactory,  substituted  water 
for  air.  The  use  of  water  in  the  direct  cystoscope  embodied  an  en- 
tirely new  principle.  At  first  thought  the  idea  of  looking  through  a 
tube  of  water  hardly  seems  practical.  The  water  medium  magnifies 
the  field  slightly  and  brings  it  out  in  clear  relief,  but  does  not  distort 
the  object  observed.  Furthermore,  it  is  less  painful  than  air  in  the 
bladder  and  is  more  easily  controlled.  Having  briefly  outlined  the  or- 
igin of  the  method  we  are  emj)loying,  I  will  discuss  the  comparative 
advantages  of  the  lens  instruments  now  used  and  the  direct  view  water 
cystoscope. 

"The  lens  instrument  offers  the  following  advantages:  1.  It  gives 
a  field  of  greater  circumference.  2.  It  permits  a  clearer  view  of  the 
anterior  wall  of  the  bladder  in  the  male.  3.  It  offers  a  more  detailed 
and  magnified  view  of  the  bladder  mucosa. 

"While  it  is  true  that  the  field  of  vision  in  an  observation  lens 
is  greater  than  through  a  direct  cystoscope,  nevertheless  with  many 
catheterizing  lenses  the  actual  diameter  of  the  field  is  not  very  much 
larger.  Moreover,  what  one  loses  in  circumference  of  the  field  is  at 
least  partially  made  up  by  the  increase  in  perspective  gained  by  di- 
rect inspection.  Although  the  anterior  bladder  wall  is  easily  viewed 
through  an  observation  lens,  still  in  the  female  it  can  be  inspected  quite 
as  easily  through  the  direct  cystoscope.  By  partially  emptying  the 
bladder  and  by  permitting  the  roof  to  sag  down,  but  little  escapes  in- 
spection in  the  male  bladder.     With  greatly  liypertrophied  prostates 


DiiU'Xrr  cvsTo.scorv  247 

il  iiin>'  ()('(';isi()ii;ill\'  liccoiiic  diriiciill  to  iii^pcd  th"  aiilcrioi-  lilaildcr  wall. 
W'liilc  llic  (l('1<Mil(Ml  and  iiia,i;iiiri(Ml  xicw  oT  llic  Madder  iiiiicosa  and  iiro- 
Icral  incali  ohlniiicd  llii'()u,i;li  a  lens  may  occasional !>•  Ix'  of  some  ad- 
vaida^c,  ju'vorllicdess  llic  picluic  ohtaincd  l)y  tlic  nnaidccl  oye  is  a 
truer  one  and  loses  no  data  of  jiraclical  \alue. 

^'Tlie  adv<iiila,i;'es  of  the  direct  \iew  ai'c:  1.  Its  .-ihipler  meelianisin. 
2.  A  clearer  view  of  tlie  iield  in  case  of  lieni()irlia,i;e.  o.  The  field  is 
]iatural,  recjuiring  no  interpretation.     4.  Use  as  iiretliroscope  as  Avell. 

"Tlie  sini]:)ler  niechanism  of  tlie  direct  cystoscope  offers  the  fol- 
lowing- advantages:  (a)  It  is  less  often  damaged  and  in  need  of  repair 
tliaii  the  line  lens  adjustments;  (b)  it  is  more  easily  sterilized  by  mo- 
mentary innnersion  in  pure  jjlienol  followed  by  washing  in  water;  (c) 
its  use  does  not  require  careful  preliminary  irrigation  of  the  bladder. 
AVitli  a  freely  1)leeding  ])ladder  mucosa  it  is  frequently  impossible  to 
obtain  a  clear  view  through  a  lens  cystoscope  in  spite  of  continuous 
irrigation.  With  the  direct  instrument,  on  the  other  hand,  we  are  look- 
ing through  a  clear  stream  of  water  Avliich  is  continuously  entering 
the  bladder  and  washing  the  observed  area,  and  bleeding  is  seldom  so 
great  as  to  render  examination  impossible.  Most  beginners  in  the  use 
of  the  lens  cystoscope  comjjlain  of  the  difficulty  in  interpreting  the 
held  observed.  Although  the  inversion  of  the  object  is  now  corrected 
by  the  latest  lenses  and  the  interpretation  is  somewhat  simplified, 
nevertheless  the  magnification  in  the  frequently  blurred  field  is  confus- 
ing to  the  novice.  On  the  other  hand,  the  direct  natural  view  is  readily 
and  accurately  interpreted  in  a  comj^aratively  short  time. 

'"The  direct  cystoscope  may  also  be  employed  as  a  iiretliroscope. 
While  the  view  thus  obtained  may  lack  the  magnified  detail  afforded 
by  the  lens  instruments,  the  actual  value  of  which  is  questionable, 
everything  of  i:)ractical  imi:)ortance  is  clearly  visible.  Although  the 
impo]"tance  of  routine  urethral  examination  has  undoubtedly  been  re- 
cently exaggerated,  an  instrument  which  will  permit  urethroscopic  as 
well  as  cystoscopic  examination  is  frequently  of  considerable  value. 
Of  particular  interest  is  the  direct  inspection  of  the  prostate  from  the 
viewi)oint  of  the  pi'ostatic  urethra  from  which  the  relative  size,  posi- 
tion, and  IVe(|uently  character  of  the  enlargement  is  I'eadily  ascer- 
tained." 

REFERENCES 

iKclly:  Bull.  Johns  Hopkins  IIosp.,  Dec,  1893. 

-Lewis:  Jour.  Culan.  and   Genito-Urinary  Dis.,   ]!i()(i,   p.   4-0. 

sElsncr:  Pilchcr's  Practical  Cystoscop}',  pp.  82,  83. 

•iLuys:  Assn.  frantj.  d'Urol.  Proc.-vcrb,  1905,  Par.,  190(i,  pp.  407-482. 


248  CYSTOSCOPY  AjStd  urethroscopy 

DIRECT  VIEW  CYSTOSCOPY  DURING  PREGNANCY 

Cystoscopic  conditions  in  general  are  particularly  unfavorable  in 
the  pregnant  woman,  whose  bladder  is  deformed  and  often  displaced. 
Indeed,  owing  to  traction  exerted  b^^  the  inferior  segment  and  com- 
pression exercised  by  the  fetal  head,  the  vesical  cavity  is  considerably 
contracted  in  certain  parts,  especially  at  the  fundus.  This  arrange- 
ment does  not  permit  the  movement  of  the  cystoscopic  jorism  to  a  dis- 
tance sufficient  to  give  a  clear  view  of  the  fundus.  IMoreover,  it  is  dif- 
ficult to  maneuver  the  elbow  of  the  indirect  cystoscope  in  the  limited 
space  thus  reserved  for  the  evolution  of  the  instrument. 

On  the  other  hand,  these  difficulties  are  not  met  with  in  direct  vi- 
sion cystoscopy;  because  of  its  straight  shape,  it  is  easy  of  evolution 
and  permits  direct  examination  of  the  different  parts  of  the  bladder,  as 


Fig.   160. — Diagrammatic    section    showing   the    aspect    of   the    bladder   in    pregnancy. 

well  as  a  clear  view  of  the  smallest  lesions,  with  their  exact  size  and 
situation. 

Bar  and  I  undertook  a  series  of  investigations  with  my  direct  vi- 
sion cystoscope  regarding  the  condition  of  the  bladder  in  pregnancy,^ 
and  among  the  facts  brought  out,  these  two  are  especially  to  be  kept 
in  mind:  1.  The  deformities  of  the  bladder  at  the  height  of  pregnancy. 
2.  The  displacement  of  the  vesical  orifices  of  the  ureters  in  certain 
females. 

1.  Deformity  of  the  Bladder  at  the  Height  of  Pregnancy. — For  a 
long  time  obstetricians  have  called  attention  to  the  deformities  and  dis- 
placements of  the  bladder  at  the  height  of  pregnancy.  These  deform- 
ities are  the  result  of  overdistention  of  the  lower  segment  of  the  uterus, 
and  particularly  of  the  engaging  of  the  fetal  head.  The  bladder  be- 
ing forced  backward,  permits  itself  to  become  distended  Avherever  pos- 
sible, and  thus  becomes  deformed. 


i)n;i:r'i'  cystoscopy  Dunixt;  piiecxaxcy 


240 


'riic  (l('\iali()iis  of  llic  hladdcf  arc  oflcii  more  apparciil  lliaii  rral. 
Tlic  iiiKMiiial  dislciiiioii  oF  llic  various  regions  of  llic  or^^aii  may  ^-ive 
llic  impression  of  a  dcxialioii  wliicli  docs  not  fcally  exist,  at  least,  as 
jiid.iA'cd  hy  the  Ncsicai  tfinoiic,  w  liidi  always  remains  in  tlie  median  line. 
AVe  ean  readil\-  iiiidersland  thai  lliis  must  l)e  so,  if  we  consider  tlie  faet 
that  at  llic  lici.^lii  oi'  prc.^iiaiicy  llic  ulcro\-esieal  ccHiilar  lissuc  is  ex- 
tremcl.N'  lax.  This  laxity  <;ives  to  llic  l)lad(ler  a  remarkable  freedom 
of  motion,  as  eom])ai-e<l  ^vit^l  tlie  iilcnis.  We  must  also  take  into  con- 
sideration the  fact  llial  llie  uietlira  (jn  the  one  liaud,  and  the  two  ure- 


Fig.   161. — Frozen   section   of  a  pregnant  female    (after  Zweifel).=     The  lateral   portion   of   the   bladder  can 
be  seen,  much  larger  than  the  median  portion. 


ters  on  the  other,  constitute  real  ligaments  for  the  trigone,  which  con- 
tribute toward  uiaintaining-  it  in  its  normal  position. 

Nevei-theless,  real  deviations  of  the  bladder  may  exist.  The  ves- 
ical ti-igone  may  not  be  median,  in  Ihe  sense  Ihat  the  two  ureteral 
orifices  are  not  equidistanl  from  llic  sagillal  V)lane.  These  deviations 
are  due  to  the  fact  thai  llie  cellular  1  issue  between  Ihc  l)ladder  and 
the  inferior  segment,  howcxcr  Hahh)  llie  lalter  may  be,  occasionally 
constitutes  hul  a  feeble  union  bclwccn  llic  Iwo  organ<,  especially  when 


250 


CYSTOSCOPY    AXD    UEETHEOSCOPY 


the  lower  segment  is  overdistended  as  is  tlie  case  at  the  height  of 
pregnancy.  Tlie  trigone  can  l3e  actually  deviated  -when  the  nterns  and 
its  lower  segment  execute  a  rotary  movement  toward  the  end  of  preg- 
nancy, so  as  to  bring  the  left  edge  of  the  organ  forward.  This  rotary 
movement  is  generallj^  encountered  when  the  lower  segment  distends 
itself  more  on  one  side  than  on  the  other;  this  condition  is  often  ob- 
served in  cervical  presentation  and  also  frequently  in  presentation  by 
the  breech. 

It  goes  without  saying,  of  course,  that  when  these  deviations  oc- 
cur, they  will  reach  their  maximum  at  labor.  But  they  may  also  be  ob- 
served during  the  last  periods  of  pregnancy  before  the  onset  of  true 
labor,  Avhen  the  painless  contractions  of  the  uterus  announce  the  im- 


Fig.   162. — Aspect  of  the  bladder  in  a   frozen   section   of   a  pregnant   female    (Barbour). '     Here   too   the   lat- 
eral  enlargement    of   the   bladder   can  be   seen. 


pending  delivery  and  alread}^  modify  the  form  and  the  position  of  the 
uterus. 

Of  the  various  deformities  of  the  bladder  which  the  cystoscope  has 
enabled  us  to  observe  in  the  living  subject,  Ave  shall  now  consider  only 
the  most  common  and  the  most  important  of  all;  namely,  that  Avliich 
is  observed  during  the  final  period  of  pregnancy  wlien  the  fetal  head 
is  fully  engaged.  We  are  at  once  struck  with  one  thing.  In  the  me- 
dian line,  the  anterior  and  posterior  Avails  of  the  bladder  are  closely 
applied  one  against  the  other.  The  organ  seems  to  be  pushed  down- 
Avard  and  flattened  by  the  inferior  segment.  Above  this  median  zone 
Avhich  often  leaves  little  space  for  the  urine,  an  uiiper  diverticulum 


iiii;i;ci'  ('^  s■|■()S(•()^^    i)i-i:ix(i   jm;k(;\axcy  251 

oL'  coii,^i<l('r;il)l(3  size  is  seen;  this  loriiis  llic  vast  jiockct  wliicli  is  out- 
lined al)()\('  llio  j)u])is  ill  so  many  ])r('^iiaiil  woiiicii. 

Tills  ])()ck-('l  cxlciids  I;i1cr;ill>-  lo  such  a  degree  tJiat  tlie  bladder 
l)eiiig  emptied,  two  •diverticula  can  be  seen  at  tlie  sides,  unequal  and 
quite  dee]).  These  diverticula  are  best  o])served  in  tlie  Trendelenburg 
position.  I'^i-equently  they  are  found  filled  Avitli  urine.  In  order  to 
understand  lliis  desei'iplion  better,  the  reader  will  refer  to  Fig.  100, 
where  the  i)icture  of  the  bladder  is  quite  characteristic.  Let  a  trans- 
verse section  be  assumed  passing  immediateh'^  in  front  of  the  neck  of 
the  bladder  and  of  the  point  of  entrance  of  the  ureters  in  the  bladder. 
Imagine  a  sac  having  two  walls,  covering  the  inferior  segment;  on  the 
median  line  the  two  walls  touch  each  other;  above,  are  the  orifices  of 
the  ureters,  U,U;  below,  the  orifice  of  the  urethra,  D,  and  on  the  lat- 
eral walls,  two  diverticula,  A,A,  which  are  the  last  to  empty  tluMu- 
selves.  In  these  diverticula  a  catheter  or  a  cystoscope  (since  we  are 
discussing  cystoscopy)  must  be  introduced  to  obtain  the  required  dry 
medium,  at  least  in  the  Trendelenlnirg  position.. 

We  have  been  able  to  demonstrate  that  this  arrangement  is  the 
usual  one  when  the  fetal  head  is  fully  engaged,  and  we  have  every  rea- 
son to  believe  that  we  have  not  been  deceived  by  appearances.  Con- 
sulting the  color  plates  at  our  disposal,  Avhicli  rejoresent  frozen  sec- 
tions, we  have  found  an  arrangement  of  the  bladder  quite  analogous 
to  that  which  we  are  describing;  and  in  a  plate  iDublished  by  Zweifel 
(Fig.  161),  representing  a  transverse  section  (passing  through  the 
promontory  and  the  upper  part  of  the  pubis)  of  a  woman  who  died  in 
labor,  the  same  arrangement  is  shown.  Barbour  has  also  represented 
the  bladder  with  a  similar  arrangement  in  a  frozen  subject  (Fig.  162). 

EEFERENCES 

iPaul  Bar  and  Geoi<;os  Luys:  Exameii  dc  la  vcssic  chez  la  fcmme  enceinte,  par  le  cystoscope 
a.  vision  direc'te   (Societe  d'Obstetrique  dc  Paris,  Session  of  March,  1006). 

sZweifel:  Zwei  neuc  Gefrierschnitte  Gebarende,  Leipzig,  ISO.T;  Plates  1  and  6,  representing 
a  transverse  section.  Tlie  Madder  is  flattened  medially:  on  the  left  side,  the  only 
side  represented,  the  organ  is  prolonged  distinctly  outward  and  is  much  less  flattened 
than  in  the  median  line. 

:!P,arl)our:     Atlas  of  the  Anatomy  of  Lalniur,  Plate  XXIT,  Edinlmrgh,  Johnston,  ISPT. 

2.  Relation  of  the  Neck  of  the  Bladder  to  the  Ureteral  Orifices. — It 
is  interesting  to  detei'mine  the  relative  position  of  the  bladder  neck  and 
the  ureteral  orifices.  Tn  the  Trendelenburg  jiosition  the  vesical  trigone 
is  hoii/ontal;  and  when  the  cystoscope  is  inserted  straight  ahead  into 
the  hiadder  and  u])  to  the  fundus,  then  v>itlidra\vii  slightly  toward  the 
bladder  neck',  wc  can  see  the  ])i-()je('ti(»n  made  by  the  transverse  muscle 


252 


CYSTOSCOPY    AXD    URETHROSCOPY 


fibers  (internreteral  ligament)  wliicli  unite  both  ureteral  orifices.  The 
latter  situated  deeply  and  laterally,  are  on  the  same  plane  as  t^ie  neck 
of  the  bladder.  But  a  quite  different  arrangement  is  noted  at  full  term, 
especially  in  the  primipara,  Aylien  the  head  of  the  fetus  has  fully 
engaged. 

In  the  noniDregnant  woman,  in  the  erect  position,  with  the  bladder 
empty,  the  anteverted  uterus  imi^resses  a  slight  transverse  fold  on  the 
vesical  trigone,  which  is  effaced  in  the  Trendelenburg  position,  because 
of  the  traction  exercised  by  the  uterus  on  the  upper  jDart  of  the  trigone. 

In  the  pregnant  woman,  especially  in  the  primipara,  this  fold  of 


Fig.  163. — Mew  of  the  bladder  and  ureteral  oritices  in  the  pregnant  female.  L^.L',  opening  of  the 
ureters  into  the  bladder;  D.  urethral  canal  opening  into  the  bladder;  B,  transverse  plicature  of  the 
trigone;  A,A,  lateral  prolongations  of  the  bladder;  C,  direction  of  the  cystoscope  as  it  enters  the  bladder; 
C,   direction  of  the  instrument   pointed  toward   the   ureter. 


the  trigone  is  often  much  more  marked  than  in  the  nonpregnant,  and 
it  can  be  readily  understood  why  it  must  be  so.  Because  the  expan- 
sion of  the  inferior  segment  is  accomplished  almost  entirely  at  the  ex- 
pense of  the  anterior  wall,  the  neck  of  the  bladder  is  pushed  backward 
where  it  is  held  firmly  by  the  uterosacral  ligament  and  their  intra- 
uterine extension.  To  a  certain  extent,  when  tlie  bladder  is  empty  or 
nearly  so,  the  vesical  trigone  responds  to  the  pull  which  the  lower  seg- 
ment exerts  on  it  tlirough  the  action  of  the  vesicouterine  cellular  tis- 
sue.    The  trigone,  thus  retracted  backward,  but  held  tightly  upward 


DiKKCT  ('^>■'r()S(•ol'^    dikixi;    pui^cxancy  253 

;iii(l  I'orwni'd  1)_\'  the  iii'clcrs  ;ni<l  (low  iiw  .".id  niid  lorward  !i>'  111"  ni'dlira, 
hccoiiK's  loldcd  on  ilscll'.  Willi  llic  woman  In  llic  'ri-ciidclcniaii-;;- posi- 
tion, lliis  plica! ni'c  is  niain1ainc(l  hccausc  ol  llic  sli,i;!il  dispiaeeinent  of 
llie  iilcnis.  Tliis  anaiii^cnicnt  avc  n'i)cal,  is  cs])ccially  inai'lvod  in  tlie 
priiiiipara,  \\licii  llic  ])i'csenlinft-  part  is  lirinlx-  cn^^a^cd  and  wlion  tlio 
bladder  neck'  is  sli-on,i;,l\-  Infiied  ])aek\vai'd;  llic  a])o\'c  ai-ran,i;('iiicnt  may 
be  lackiii*;'  in  nuiltipar;T\ 

The  appearance  of  tlie  Jjladder  wlicii  the  fetal  liead  is  iiniily  en- 
gaged, is  well  shown  in  P'ig.  168.  In  this  position  the  ureters  do  not 
enter  the  bladder  on  the  same  level  as  the  urethra,  l)ut  more  or  less 
higher  np. 

3.  Pathologic  Vesical  Deformities  and  their  Relation  to  Ureteral 
Catheterization. — The  deformities  wliich  we  have  just  discussed  are 
not  without  interest  from  the  pathologic  point  of  view,  and  they  should 
not  be  forgotten  when  the  ureters  have  to  be  catheterized  with  the  pa- 
tient at  full  term. 

It  is  well  to  rememl)er  above  all,  that  the  lateral  diverticula  in  the 
bladder  emi)ty  themselves  poorly;  these  partial  retentions  are  there- 
fore of  interest  in  connection  with  the  tenacity  of  vesical  infections 
during  pregnancy.  In  one  instance,  I  Imxe  been  able  to  note  that  the 
lesions  of  the  vesical  wall  and  the  purulent  deposits  simulating  false 
membranes,  were  found  particularly  in  the  right  side  of  the  bladder, 
external  to  the  vesical  entrance  of  the  right  ureter,  where  the  bladder 
presented  a  sort  of  lateral  diverticulum  which  emptied  itself  badly. 

We  may  presume  that  the  pressure  exerted  by  the  inferior  segment 
ujoon  the  uj^per  part  of  the  trigone,  and  the  terminal  portion  of  the 
ureters,  favors  the  retention  of  the  urine;  that  is  perha]:>s  not  insignifi- 
cant from  the  point  of  view  of  the  frequency  with  which  the  intra- 
ureteral  retention  of  mine  during  j^regnancy,  is  observed. 

On  the  other  hand,  fi'om  the  standpoint  of  ureteral  catheterization, 
the  discovery  of  the  ureteral  orifices  will  be  particularly  facilitated, 
if  we  bear  in  mind  tlie  fact  that  these  orifices  should  be  sought,  when 
the  head  is  engaged,  not  below  and  outward,  as  in  the  nonpregnant 
subject,  but  further  forward,  above  the  transverse  depression  which 
projects  above  the  bladder  neck. 

In  l)rief,  the  following  rule  may  be  laid  down:  In  pregnancy,  wlien 
the  ureteral  orifices  are  not  I'ound  innnediately,  by  the  method  of  Luys 
which  has  just  been  dcscril^ed,  they  jiuist  be  looked  for  higher  uj:)  and 
furlhci-  forward;  llic\-  will  llien  1)0  easily  found. 


CHAPTER  VII 

CATHETERIZATION  OF  THE  URETERS 

Ureteral  catheterization  constitutes  one  of  the  most  impoi'tant  and 
interesting  applications  of  cystoscopy.  The  introduction  of  a  catheter 
into  the  ureter,  not  only  makes  possible  the  complete  exploration  of  this 
canal  throughout  its  length  and  also  of  its  corresponding  renal  pelvis, 
but  it  has  numerous  other  applications  besides ;  to  these  we  shall  return 
later  on.    The  most  important  are  the  following: 

1.  The  study  of  stricture  or  obliteration  of  the  ureter  and  of  the 
therapeutic  measures  applicable  to  these  lesions. 

2.  The  search  for  calculi  in  the  ureter. 

3.  The  treatment  of  renal  colic. 

4.  The  exploration  of  the  kidney  pelvis  either  for  a  calculus,  or  as 
a  general  diagnostic  measure,  or  to  determine  the  capacity  of  the  pelvis. 

5.  As  a  therapeutic  measure,  to  irrigate  the  renal  pelvis  in  certain 
forms  of  mild  pyelitis. 

6.  As  a  therapeutic  measure  to  assure  the  proper  caliber  of  the 
ureter  after  ureterolithotomy. 

7.  As  a  prophylactic  measure  to  safeguard  the  ureters  during  gjn- 
ecologic  operations,  such  as  for  cancer,  fibroma  of  the  uterus,  etc.- 

8.  For  drainage  and  rapid  closure  of  certain  fistulse  after  ne- 
phrotomy. 

9.  For  the  treatment  of  certain  hydronephroses. 

How  large  a  field  is  offered  by  ureteral  catheterization  is  clearly 
evident,  and  we  shall  begin  by  studying  the  most  practical  methods  of 
catheterization.  We  have  two  methods  at  our  disposal, — with  the  in- 
direct (prismatic)   cystoscope  and  with  the  direct  vision  cystoscope. 

URETERAL  CATHETERIZATION  WITH  INDIRECT 
VISION  CYSTOSCOPY 

Of  all  the  indirect  vision  cystoscopes  Avhich  have  been  especially 
devised  for  ureteral  catheterization,  we  distinguish  two  principal  types; 
these  have  been  studied  carefully  in  the  interesting  monograph  of 
Tmbert : 

1.  Instruments  in  Which  the  Catheter  Is  Not  Deflected. — 

Brenner's  Cystoscope. — Brenner  seems  to  have  been  the  first  to 

254 


CATTTETETJZATrOX    OF    THE    ItllETEl^S 

iiiiiodiKM"  a  llcxiltle  catlieter  into  tlie  female  ureter,  in  1887.  His  m- 
striiincnt  was  a  niodifieation  of  Nitze's  cystosfO])o  No.  2,  and  adapted 
to  liis  s])ec'ial  ])iii|)os('.-  It  consisted  of  a  piisiiuitie  (indireet)  eysto- 
scope  willi  the  N'isual  field  and  lamp  siluatcil  on  tlic  convexity  oi'  llie 
beak.  Inferioi'ly  and  runnin.u-  llii-ou,i;li  the  entire  lenf;tli  of  tlie  cysto- 
scope  was  a  little  channel  for  the  ureteral  cathetei'.  '^i'lie  inventor  suc- 
ceeded quite  easily  in  eatlieterizing  the  female  ureter,  but  in  tlic  male 
all  his  efforts  failed  completely. 

BoissEAU  DU  Eociier's  Megaloscope  for  ureteral  catheterization 
presented  tlie  same  arrangement  and  consequently  offered  the  same 
disadvantag-es.  The  great  difficulty  in  catheterizing  the  ureter  with 
these  instruments  lay  in  the  fact  that  the  catlieter  could  not  be  de- 
flected and  that  it  had  to  x^ass  in  a  straight  line  from  the  urethra  to 
the  ureter.  It  was  therefore  necessary  to  tilt  the  handle  of  the  cysto- 
scope  very  obliquely,  and  this  was  done  only  with  great  difficulty. 

2.  Instruments  in  Which  the  Catheter  Can  Be  Deflected. — AVith 
the  ol)ject  of  remedying  the  principal  faults  just  mentioned,  tlie  fol- 
lowing instruments  were  devised  and  constructed: 

TiLDEiSr  Brown's  Cystoscope. — Brown  utilized  Brenner's  instru- 
ment. He  modified  it  by  constructing  a  fine  stylet  that  could  be  in- 
serted into  the  interior  of  the  ureteral  catheter.  This  stylet  had  an 
elbowed  vesical  extremity,  so  that  it  could  Ije  extended  about  three 
centimeters  beyond  the  tip  of  the  cystoscope.  The  cystoscope  is  intro- 
duced into  the  bladder,  the  catheter  canal  being  closed  with  an  ob- 
turator. The  latter  is  then -removed  and  replaced  by  the  catheter  and 
its  stylet.  The  ureteral  orifice  is  then  sought,  and  when  found,  the  tip 
of  the  stylet  is  directed  upon  it.  By  means  of  the  stylet  the  extremity 
of  the  catheter  can  l^e  given  any  position,  and  it  thus  becomes  an  easy 
matter  to  direct  it  toAvard  the  ureter.  The  author  succeeded  in  cathe- 
terizing the  male  ureter  with  this  instrument."^ 

Nitze's  Cystoscope  (First  Model  of  1896). — In  his  first  experi- 
ments with  uretei-al  catheterization,  Xitze  surrounded  his  simple  cysto- 
scope with  an  oval  metallic  sheath  in  which  the  uretei'al  catheter  was 
to  pass.  This  sheath  extended  beyond  both  ends  of  the  cystoscope,  so 
as  to  permit  the  easy  introduction  of  the  catheter  on  the  one  hand,  and 
also  to  give  it  the  necessary  flexibility,  on  the  other.  The  metallic 
sheath  was  movable  forward  and  backward,  and  From  side  to  side,  so 
that  the  tip  of  the  catheter  could  be  deflected  in  all  directions  and  thus 
brought  to  the  orifice  of  the  ureter. 

This  ])rimitive  instrument  bad  the  gi-eat  disadvantage  of  being 
too  bulkv,  and   its  iiit rodudioii   was,  therefore,  difficult.     It  was  con- 


256 


CYSTOSCOPY    AjSTD    URETHROSCOPY 


sequenth'  soon  abandoned  by  its  inventor,  who  adox)ted  later  improve- 
ments and  developed  another  model,  wliich  is  still  very  widely  used  at 
the  present  day  (Fig.  164). 

Casper's  Cystoscope. — This  instrnment  (Fig.  165)  ai3art  from  the 
cystoseope  proper,  comj)rises  a  catlieter  canal  situated  superiorly.    Tliis 


Fig.    164. — ISiitze's   cystoscope   for   wreteral   catheterization;    improved   model. 

canal  is  covered  by  a  deflector  which  serves  to  control  the  bending  of 
the  catheter;  so  that  the  further  the  deflector  is  introduced,  tlie  more 
will  the  catheter  be  bent,  and  the  more  it  is  withdrawn,  the  less  will 
the  catheter  be  deflected  from  the  straight  Ime. 

This  instrument,  which  can  be  introduced  more  easilv  than  Nitze's 


Fig.  165. — Casper's  ureteral  cystoscope.  A,  electric  lamp;  B,  prism;  C,  inferior  orifice  of  a  channel 
(gutter)  which  runs  along  the  entire  length  of  the  instrument,  and  which  is  transformed  into  a  closed 
canal  by  the  sliding  rod  D,  represented  separately  as  M.  The  ureteral  catheter  traverses  this  canal;  E, 
ocular. 

early  model,  does  not,  however,  permit  the  easy  introduction  of  a  ure- 
teral catheter.  Casper,  therefore,  devised  a  more  recent  model  (Fig. 
166)  in  which  the  groove  for  the  ureteral  catheter  is  divided  into  two 
parts  wdiicli  makes  possible  the  catheterization  of  both  ureters  with- 


Fig.    166. — Casper's    doable    ureteral    cystoscope. 


out  withdrawing  the  cystoscope  from  the  bladder.     This  constitutes  a 
very  important  improvement. 

Albaerax's  Cystoscope. — Practical  catheterization  of  the  ureter 
Avas  made  possible  by  Albarran,  who  described  it  in  1897  (Fig.  167). 
His  cystoscope*  is  comijosecl  of  several  distinct  parts:    1.  The  oxDtica] 


CATIIKTIOItl/ATlON     Ol'    T  1 1  K    I '  IM/I'KIIS 


257 


jioi'lioii,  I  lie  .^:('iii'r;il  ;iit;iii,l;ciiicii1  of  w  liicli  i-  llinl  of  ;iii  oi  tli iin rv  cvslo- 
scojx'.  The  I\\(»  iirclcrnl  or  I  ri-i^;i1  iiii;-  poilioiis  iii;i>-  Ix'  niomilcil  upon 
lliis  pnrl.  ;i.-  (IcsiicJ.  l'.  The  iiiclcr.-il  iiorlion  consists  of  an  open 
i;i-()()\(',  wliicli  is  pi-()pcil>-  .'Kljiislcd  lo  llic  o|)1i(';il  poi-Jioii.  Aloni:-  tlic 
sides  of  this  ,i;i'()o\('   ai'c  two  lliiii   stems  ol"  steel    w  liicli   arc  ('Oime('t('<l 


I'iR.    1()7. — AlLatran's   simple   cystoscope. 

with  a  (lelleclof  at  llie  o|)ti('al  pai1  of  the  e_\'st()se()])e.  Tliis  (h'flectoi' 
articulates  \vitli  a  ,i;i-o()vc,  and  can  assume  any  ])osition,  l)et\\'cen  the 
liorizontal  and  an  aii,i;ie  of  loO  de.^i-ces.  AVlien  tlie  ■deflector  is  in  tlie 
last  ])Ositi()]i,  i(  is  ])ei-IVctly  adjusted  to  tlie  terininal  iiart  of  tlie  GTOOve; 
this   is  tlie  ])osition   ol'  the   instrunient   wlien   not   in  use.     Tlie  move- 


Fig.   168. — AII)arran's   cystoscope   provided   with    its   ureteral   attachment. 

menis  of  the  deflector  ai'e  controlled  l)v  a  wheel,  wliicli  is  i)laced  near 
llie  oculai-  extremity  of  tlie  instrument  and  raises  or  lowers  tlie  de- 
flector. The  vault  of  the  oroove  is  traversed  by  a  canal  for  the  ure- 
teral catlu^cr;  the  catheter  emero-es  in  front  of  the  deflector  and  lies 
dii'ectly  upon  it  when  it  is  inserted.     By  maneuveriii.ii-  the  wheel,  this 


Fig.    169. — Albarran's    deflector,    whicli    moves   tl;e   catheter   and    thns   permits    ureteral    catheterization. 

arranu-eiiieiit  peniiils  the  tip  of  the  catheler  to  tak(,'  any  jtosition  he- 
Iween  the  horizontal  and  an  aii.ule  of  140  (l(\jvi"<.'<'!^-  Thus  th(^  ani;'le  of 
the  catheter  ina>'  he  chaii,i;'ed  a1  will.  The  iir"1ernl  ('li;iiiiiel  ])resents 
exiernally  a  lillle  hox  which  hears  a  small  round  riihher  shield  or  cap, 
l)ierced   I'oi-  the   passa,i;('  of  Ihe  catheler.      \\y  tijA'litenin.i;-  the  screw  to 


PLATE  XVI 

Fig.  1. — Typical  aspect  of  a  tuberculous  ureteral  orifice,  indicating  an  ac- 
companjdng  tuberculous  pyonephrosis.  A  few  ulcerations  resembling 
nail  scratches  are  seen  outside  of  the  ureteral  orifice. 

Fig.  2. — Ttiiarculous  ulcerations  of  the  bladder  seen  with  the  direct  vision 
cystoscope. 

Fig.  3. — Tuberculous  ulcerations  of  the  bladder  treated  with  applications 
of  the  silver  stick,  through  the  direct  vision  cystoscope.  The  ulcerations 
represented  in  this  figure,  are  the  same  as  those  in  Fig.  2,  but  the 
central  ulcerations  have  been  touched  with  the  stick.  The  impressions 
of  the  silver  pencil  are  easily  recognized. 


Fig.  1. 


FiK.  2. 


PLATE  XVI 


Fig.  3. 


catiii:tI':i;i/ati()X  ok  tiik   iiiF/ruRS 


259 


a  greater  or  Jess  degi'ee,  llu;  I'lilthci-  shield  is  llaUcjiKMl  and  the  vesical 
fluid  is  prevented  From  escaping,  w  liile  the  catlieter  is  enabled  to  move 
freely  to  and  Ito. 

Al)ove  tlie  ureteral  cliaiiiiel,  tliere  is  another  canal,  provided  with 
a  little  sto23cock;  this  channel  is  nsed  for  cleansing  tlie  lenses  or  irri- 
gating the  bladder.  This  cystoscope  and  its  attachment  has  a  caliber 
of  No.  25  Charriere. 

3.  The  irrigating  portion  is  also  closely  fitted  by  a  groove  to  the 
optical  ai3i:)aratns.  Tn  tlie  anterior  convexity  of  this  groove  is  found  Jin 
irrigating  canal  v.hich  opens  near  the  lens  and  has  a  stopcock  at  its 
outer  extremity.  All  of  this  constitutes  an  irrigating  cystoscope  which 
permits  irrigation  of  the  bladder  and  cleansing  of  the  lenses.    The  de- 


pojiyi'/^  ""■ 


C. 


Fig.    170. — Bierhoff's    modification    of    Albarran's    cystoscope,    permitting    the    simultaneous    catheterization    of 

both    ureters. 


Hector  renders  catheterization  simple  and  practical,  and  has  been 
adopted  nniversally  by  c^^stoscope  makers. 

Israel's  Cystoscope. — This  instrument  differs  from  Nitze's  by 
having  a  doulile  ureteral  canalization,  thus  permitting  the  simultane- 
ous catheterization  of  both  nreters,  and  also  by  having  a  movable  irri- 
gating attachment. 

Bierhoff's  Cystoscope. — This  is  an  Al])arran  cystoscope,  modified 
so  as  to  effect  the  simultaneous  catheterization  of  both  ureters  (Fig. 
170).  In  this  instrument,  the  optical  portion  to  which  the  lamp  is  fixed 
is  movable;  it  also  avoids  the  disadvantage  of  tlic  two  meters  cross- 
ing each  otliei'  when  the  cystoscope  is  willidrawn  ami  the  eatlicters 
left  in  s'lfu  in  tlicii-  i-cspective  ureters. 


260 


CYSTOSCOPY   AXD    URETHROSCOPY 


WossiDi.o's  Cystoscope. — This  is  also  a  double  catheterizing  iii- 
strnment.  In  this  cystoscope  the  lens  and  the  lamp  are  situated  on  its 
convexity,  so  that  it  is  a  simple  matter  to  withdraw  the  instrument  and 
leave  the  ureteral  catheters  in  situ,  without  turning  the  cystoscope. 
Its  caliber  is  23  Charriere,  and  the  ureteral  channels  will  accept  No.  5 
or  6  catheters,  or  even  a  single  catheter  of  No.  7  caliber. 

Frank's  Cystoscope. — Frank,  of  Berlin,  constructed  a  cystoscope 


Fig.   171. — Freudenberg's  cystoscope  for  catheterization  of  both  ureters. 


with  a  correct  image  for  the  catheterization  of  both  ureters  by  the  ac- 
tion of  a  double  wheel  which  controls  the  deflector  of  each  catheter 
separately. 

Freudeistberg 's  Cystoscope. — This  author  devised  a  combined  cyst- 
oscope for  catheterization  of  the  ureters  and  bladder  irrigation.''    This 


Fig.    172. — External   tube   of   Freudenberg's    cystoscope. 

was  first  presented  before  the  Urological  Congress  of  Paris  in  1904; 
various  subsequent  improvements  were  sliown  l)efore  the  Congress  of 
the  International  Surgical  Society,  held  at  Brussels,  in  September, 
1905. 

This  cystoscope  presents  two  new  j)rinciples :  In  the  first  place,  tlie 


l^S 


Fig.    173. — Optical    portion    (telescope)    of    Freudenberg's    cystoscope. 

lens,  the  lamp  and  the  deflector  are  all  on  the  convexity  of  the  instru- 
ment; secondly,  instead  of  a  special  channel  for  the  ureteral  catheter, 
there  is  a  free  space  above  the  mounting  of  the  optical  portion  in 
which  the  catheters  move  to  and  fro  freely. 

One  or  both  ureteral  catheters  may  be  directed  by  a  guide  placed 
in  this  free  space;  this  guide  has  a  deflector  at  its  vesical  extremity 


CATll  KTKIM/AI'ION    OF    'J" 


IKIiTERS 


2G1 


siiiiilai'  1()  llinl  of  Alharraii.  J^'iiially,  llic  optical  jjorli(jii  i.-  not  cir- 
cular, l)iil  llatlciicd  on  one  side,  so  tliat  the  visual  field  is  made  larger. 
Moreover,  llic  cnlirc  optical  ai)j)ai'alus  iticliidiii:.':  llio  ui'ctci'al  guides 
can  Ix'  I'ciiiovcd  s('|)aratcl_\'  •Aillioul  llic  iicccssit\-  of  witlidrawing  tlie 
entire  inslrunient. 

The  advantages  oT  this  iiisliuiiiciit  are  especially  uotcwortliy  in 


^=S 


Fig.    174. — Irrigating    tulie    of    Frcudenberg's    cystoscope. 


ureteral  catlieterization.  Indeed  after  the  ureteral  catheters  have  been 
iutroduced,  if  it  is  desired  to  leave  them  in  the  ureters  without  the 
cystoscope,  it  is  unnecessary  to  turn  the  instrument  on  its  axis  in  order 


Fig.   175. — Ureteral    catheter    guides    for    Freudenberg's    cystoscope. 


to  withdraw  it.  Tlie  optical  portion  having  been  removed,  it  is  a  sim- 
IDle  matter  to  withdraAv  the  cystoscopic  tube  by  sliding  it  above  the 
catheters  without  dragging  them  along.  Another  advantage  is  the 
possibility  of  using  larger  ureteral  catheters  than  are  possible   ^vitll 


Fig.  176. — Cross  section  of  Frcudenberg's  cystoscope.  A,  optical  portion  of  an  ordinary  cysto- 
scope; B,B.  used  more  than  portion  A  for  the  optical  portion  of  Frcudenberg's  cystoscope;  1  and  2, 
ureteral  catheters. 


oilier   instruments.      I^'iiially,    the   ])ladder  can    he    irrigated  with    this 
cystoscope  witliout  removing  the  entire  apparatus. 

Baer's  Cystoscope. — The  principle  of  this  instrument"  is  based  on 
the  fact  that  the  laniji  is  o])en  on  two  sides.    The  optical  apparatus  is 


262  CYSTOSCOPY    AXD    UEETHROSCOPY 

easily  intercliangeable,  and  permits  the  examination  of  tlie  entire  ves- 
ical cavity,  of  simple  or  double  ureteral  catheterization,  and  e^en  of  a 
few  intravesical  maneuvers.  The  many  adaptations  of  this  cystoscope 
explain  the  name  ''universal  cystoscope"  which  is  generally  given  to 
it.  But  it  is  hard  to  keep  it  in  order.  It  is  preferable  by  far  to  have 
several  cystoscopes  each  of  which  should  be  used  for  its  own  special 
purpose. 

Apart  from  the  cystoscojDes  just  mentioned,  the  manufacturers 
have  in  recent  years  devised  a  series  of  improved  models  in  Avhich  the 
visual  field  has  been  enlarged  and  the  eiuployment  of  relatively  large 
ureteral  catheters  made  possible.  However,  No.  8  is  generally  a  max- 
imum size,  beyond  which  it  is  difficult  to  pass.  Likewise,  double  cathe- 
terization of  the  ureters  has  undergone  considerable  improvement 
with  prismatic  cystoscopes,  with  the  result  that  this  important  pro- 
cedure is  being  carried  out  with  comparative  facility.  [American 
cystoscope  makers  have  made  Avonderful  progress  in  the  past  few  3^ears 
in  this  industry  and  are  noA\'  providing  unrivalled  instruments  for  ex- 
amination, catheterization,  and  intravesical  operative  purposes.  Only 
within  the  last  few  months,  one  manufacturer  has  jDut  on  tlie  market 
a  universal  instrument,  having  a  comj)aratively  small  caliber,  which, 
nevertheless,  has  a  large  visual  field,  a  strong  illumination,  and  a  single 
shaft  which  can  be  utilized  for  all  cystoscopic  purposes,  thus  making 
it  possible  to  perform  all  endo vesical  work  with  this  single  instru- 
ment.— Editor.] 

REFEREN^CES 

ilmbert:     Le  catheterisme  des  ureteies  par  les  voies  naturelles,  Montpellier,  1898. 

2Breuner:     Leiter  catalogue,  Vienna,  1887. 

sBrown,  F.  Tilden:     Johns  Hopkins  Hospital  Reports,  September,  1893. 

4Albarran:      Maladies   chirurgieales   du  rein   et   de  I'uretere,  in   Traite   de   Chirurgie,   by   Le 

Dentu  and  Delbet,  Paris,  1899,  Tiii,  608. 
sFreudenberg :     Ann.  geuito-urin.,  March  15,  1906,  pp.  401-411. 
6Baer:     Un  uouveau  cystoscope,  Tr.  Assn.  franc.  d'Uroi.,  1904,  p.  802. 

URETERAL  CATHETERS 

There  are  three  types  of  ureteral  catheter  which  are  most  com- 
monly used;  i.e.,  with  an  olivary  tip,  Avith  a  round  end,  and  Avith  a 
flutelike  beak.  These  models  are  A^ery  much  to  be  preferred  esiDccially 
Avlien  dealing  Avith  a  normal  ureteral  orifice.  Catheters  Avith  an  oliA^ary 
tip  are  x^articulaiiA^  couA^enient  for  ureteral  orifices  Avliich  are  narroAV, 
strictui'ed  or  otherAvise  diseased,  for  they  can  be  inserted  more  easily 
than  the  other  types.  The  flute-tii:)  catheters  are  esi)ecially  desirable 
for  therapeutic  purposes.     The  catheter  is  generally  about  70  centi- 


CATii  i:r!;i;i/.\'ri(».\   oi-    'I'iik   ii;i:'ii:k.s  JIjo 

meters  ill  Irnnlli,  aiiil  i>  iisii;ill>'  .uradiiatc*!  in  (•ciiliiiiclei's.  Tlic  calilx'i' 
vai'ics  Troiii  Xo.  5  to  Xo.  8;  tlir  sizes  inosl  coiiiiiioiily  iisecl  are  Xos.  (i 
and  7. 

TECHNIC  OF  URETERAL  CATHETERIZATION 
WITH  THE  INDIRECT  CYSTOSCOPE 

To  ])ra('li('e  callielerizatioii  willi  llie  cystoscope,  certain  systematic 
ste])s  are  essential.     These  ai'e  (lesci'ilxMl  l)y  Alhari'an,  as  follows: 

1.  Preparation  of  the  Instrument. — All  the  parts  are  sterilized, — 
cystoscope,  eatlieteis,  foreeijs,  electric  condiictino;  ^\•i^os, — in  a  formalin 
sterilizer.  The  hands  of  the  operator  are  sterilized  as  if  for  an  opei'a- 
tion.     The  instrument  is  thoronglily  tested  in  all  its  parts.     It  sliould 


Fig.    177. — Position    of    the    cystoscope    and    the    hands    in    catheterizing    the    left    ureter    (Gorodichze    and 

Ilogge)  .1 

be  well  cleaned  and  the  lamp  in  perfect  ordei".  The  catheter  is  in- 
serted into  the  ureteral  canal,  care  being-  taken  to  have  it  ^vell  lubri- 
cated with  .lilycerin  so  that  it  will  slide  in  easily. 

2.  Preparation  of  the  Patient. — In  tlie  male,  the  ojx'iator  sliould 
be  assured  that  the  calilx'r  of  the  urethra  ^^"ill  admit  a  Xo.  25  French 
sound  easily.  In  both  sexes  the  bladder  is  washed  out  thoroughly  so 
as  to  secure  as  clear  a  visual  field  as  jjossible;  it  is  then  iilled  with  150 
to  200  c.c,  of  boric  solution,  the  minimuni  amount  of  lluitl  for  cystos- 
co])y  being  from  50  to  GO  c.c. 

l\.  Introduction  of  the  Instrument. — The  tip  of  the  instrument  is 
lubricated  with  steiile  u'lvcerin  and  introduced  into  the  urethra  like  an 


264 


CYSTOSCOPY    AND    URETHROSCOPY 


ordinary  sound,  wliile  an  assistant  protects  the  catheter  from  external 
contact.  ^ 

4.  Finding-  the  Ureteral  Orifice. — The  cystoscope  is  introduced  far 
enough  for  its  tip  to  be  free  in  the  bladder.  The  beak  is  then  turned 
downward  and  outAvard,  giving  it  an  inclination  of  about  30  degrees  to 
the  horizontal.  The  lamp  is  then  lighted  and  the  ureteral  orifice  will 
quickly  be  seen. 

5.  Getting  the  Ureteral  Orifice  Into  the  Visual  Field. — When  the 
ureteral  orifice  has  been  found,  it  is  well  to  fix  it  so  that  the  intro- 
duction of  the  catheter  will  be  made  more  easily.  In  a  general  way  the 
button  attached  to  the  ocular  of  the  cystoscope  may  be  used  as  a  guide 


Fig.    178. — Position    of    the    cystoscope    and    the    hands    in    catheterizing    the    right    ureter    (Gorodichze    and 

Hogge) . 


to  bring  the  ureteral  orifice  and  the  beak  of  the  instrument  as  closely 
together  as  possible.  The  latter  will  be  very  near  the  ureteral  orifice, 
and  the  catheter,  in  emerging  from  the  cystoscope,  will  have  a  rela- 
tively short  passage  to  make  to  enter  the  ureter. 

6.  Position  of  the  Surgeon's  Hands. — At  this  moment  the  position 
of  the  operator's  hands  is  important.  One  hand  holds  the  cystoscope 
in  position  and  manipulates  the  wheel  which  controls  the  deflector;  the 
other  hand  inserts  the  catheter.^  In  catheterizing  the  right  ureter,  the 
right  hand  controls  the  cystoscope  and  deflector  and  the  left  inserts  the 
catheter;  for  the  left  ureter,  the  left  hand  controls  the  deflector  and 
the  right  inserts  the  catheter.    In  a  general  way,  it  is  w^ell  to  use  both 


CATiiK'i"i:i:i/A'ri()X  oi-  'I'iik   ri;i':Ti:i;s 


2(1.") 


hands  sijimltaiM'ouslv- ;  llial  is,  while  one  hand  is  iiisciiiii.t;-  tlic  catheter, 
the  other  hand,  at  (he  same  time  controls  llic  inoNcnicnts  oT  the  (h'- 
llcctoi-  and  thus  ^■iii(h'S  tlie  cathetei-. 

7.  The  Ureteral  Catheter  is  Inserted  Gently.  'I'hc  catheter  a])- 
])('ars  in  the  \isual  licld,  and  as  ahovc  (h'sci-ihcd,  the  (h^nector  is  low- 
civd  so  that  the  tio  of  the  catheter  is  seen  near  the  pri.-in,  considerahly 


inau'lillied 


Fig.   179. 


Fig.   180. 


Fig.    181. 


Fig.  182. 


Fig.   179. — Ureteral   catheter   in   favoral)lc   position    for   easy    entrance    into    the    ureteral    onlicc. 

Fig.    180. Ureteral    catheter    in    poor    position,    and    can    not    enter    the    ureteral    orifice   without   great 

difficulty. 

Fig  181. — The  ureteral  catheter  has  entered  tlie  rit;ht  ureter.  The  button  indicator  on  the  cysto- 
scope  is  well  placed  vat  eight  o'clock).  The  ureteral  orilice  is  ir.  line  with  its  prolongation  (Gorodichze 
and   Ilogge). 

Fig  182.— The  ureteral  catheter  has  entered  the  left  ureter.  The  button  indicator  on  the  cysto- 
scope  is  well  placed  (al  four  o'clock).  The  ureteral  orit^ce  is  in  line  with  its  prolongat  on  (Gorodichze 
and  Iloggc). 

S.  The  Catheter  Tip  is  Inclined  in  the  Direction  of  the  Ureteral 
Orifice.— Idiu  tip  oL*  the  catheter,  -eiitly  i)Ur^lied  forward  and  bent  by 


266  CYSTOSCOPY   AXD    URETHROSCOPY 

the  deflector,  as  desired,  recedes  from  the  prism,  becomes  smaller  and 
enters  the  ureteral  orifice. 

9.  The  Catheter  Penetrates  the  Ureteral  Orifice. — This  is^ perhaps 
the  most  delicate  movement  in  ureteral  catheterization.  Using  both 
hands,  as  above  suggested,  the  cystoscope  is  raised  or  lowered  at  the 
same  time  so  that  the  catheter  will  enter  the  ureteral  orifice  more  eas- 
ily. The  tip  of  the  catheter  should  be  given  the  same  direction  as  the 
ureter  (Fig.  179)  to  avoid  its  striking  the  bladder  wall,  which  will  hap- 
pen if  the  tip  is  too  high  or  too  low  or  in  front  of  or  behind  the 
orifice  (Fig.  180). 

The  ureteral  catheter  having  entered  the  lips  of  the  meatus,  it  is 
an  easy  matter  to  advance  it  up  to  the  pelvis.  It  is  well,  for  a  moment, 
to  leave  tlie  deflector  in  the  position  which  has  facilitated  the  intro- 
duction of  the  catheter;  it  will  then  be  found  much  more  convenient  to 
lower  the  deflector,  as  this  enables  the  catheter  to  slide  more  easily  into 
the  ureter.  Otherwise  the  catheter  may  rub  against  the  ureteral  wall 
and  unforeseen  accidents  may  occur. 

On  the  other  hand,  when  the  operator  is  assured  that  the  ureteral 
catheter  has  penetrated  its  entire  length  without  difficulty,  he  may  be 
certain  that  its  tip  has  reached  the  pelvis.  In  order  to  determine  when 
"the  advance  of  the  catheter  should  be  stopped,  the  best  criterion  is 
either  to  judge  by  the  resistance  felt  by  the  hand,  or  as  is  most  often 
the  case,  by  the  fact  that  its  progress  has  ceased  and  that  it  bends  upon 
itself  at  the  ureteral  orifice.  This  bending  of  the  catheter  at  the  orifice 
indicates  that  its  extremity  has  reached  the  pelvis ;  it  is  well  to  with- 
draw the  catheter  at  this  point  one  or  two  centimeters,  so  as  to  i)revent 
injury  to  the  renal  parenchyma. 

10.  Withdrawing  the  Cystoscope  and  Leaving  the  Catheter  In  Situ. 
— The  catheter  being  in  position,  the  deflector  is  lowered  so  that  it  lies 
flat  against  the  cystoscopic  tube.  This  precaution  is  absolutely  essen- 
tial, and  one  not  to  be  forgotten,  in  order  to  avoid  injury  to  the  urethra 
and  the  severe  pain  that  accompanies  it.  Next,  the  lamp  is  extin- 
guished, by  turning  off  the  current.  This  done,  the  cystoscope  is  de- 
pressed in  line  with  the  axis  of  the  body,  one  hand  feeds  the  ureteral 
catheter  into  the  cystoscope,  while  the  other  withdraws  the  tube. 
AVlien  the  beak  of  the  c3^stoscope  has  reached  the  meatus,  the  ureteral 
catheter  is  grasped  with  two  fingers,  while  the  operator  withdraws  the 
cystoscopic  tube  and  thus  leaves  the  catheter  in  place. 

REFEREliTCE 

iGorodichze  and  Hcgge:      Catlieterisme  ureteral  at   diagnostic   des  affections   renales,   Liege, 
Ch.  Desser,  1913. 


CATIIIOTKIMZATION    OV    TIIK    URETERS  207 

URETERAL  CATHETERIZATION  WITH  THE 
DIRECT  VISION  CYSTOSCOPE 

( iriiiirdd,  of  \'i('iiiia,'  seems  to  litivc  IxM'ii  tlic  lirsl  to  jji'ad  ice  calli- 
('t<'i'i/a(i(»ii  of  tlic  iii'ctci-  willi  a  (lircct  vision  cystoscoix'.  His  insli-ii- 
iiieiit  consisted  of  a  metallic  tube  l)lackeiie<l  inside,  with  a  mii'ioi-  ])la('e<l 
at  its  extremity.  A  frontal  mirror  with  an  electric  lain]),  ])rovide(l  the 
luminous  rays  and  revealed  the  ureteral  orifices. 

For  ui-eteral  cathetei'ization,  Ciriinfehl  made  use  of  a  special  cath- 
etei-,  the  caliher  of  which  was  No.  6  Charriere,  and  which  he  iuti'oduced 
into  the  bladder,  not  through  the  endoscopic  tube,  Init  along  its  ex- 
terior wall.  This  catheter  was  traversed  by  a  metallic  wire  whicli  ter- 
minated at  one  of  its  extremities  in  a  ring,  by  which  the  wire  could  be 
pulled.  Two  other  fixed  rings  formed  a  fulcrum.  The  otlier  extremity 
was  jointed  in  such  a  manner  that  the  catheter  could  be  bent  more  or 
less  and  made  to  assume  a  variable  acute  angle  with  the  rest  of  the 
catheter. 

The  tube  was  introduced  into  the  uretlira.  Next  the  catheter  was 
inserted  into  the  bladder,  in  such  a  manner  that  the  catheter  was  placed 
on  the  left  side  of  the  tube  when  the  right  ureter  was  to  be  catheter- 
ized,  and  vice  versa.  The  operator  then  sought  tiie  ureteral  orifice 
through  the  endoscope,  and  when  it  was  fou^id,  the  catheter  was  genth' 
inserted  into  the  meatus.  The  endoscope  ^yas  next  easily  withdrawn 
from  the  urethra,  and  the  catheter  left  in  situ. 

Pawlick,  in  1896,-  catheterized  the  ureter  with  a  method  different 
from  that  which  he  first  used;  this  consisted  of  an  endoscopic  tube 
which  we  have  already  described  (see  page  58),  with  whicli  he  could 
see  and  catheterize  the  ureteral  orifices  with  the  aid  of  the  special 
catheter  shown  in  the  accompanying  illustration  (Fig.  183).  He  even 
pu])lished  numerous  reports  in  which  he  was  able  to  apply  his  pro- 
cedure, but  only  in  the  female." 

Kelly's  Method. — Howard  Kelly,  of  Baltimore,  has  rendered  most 
im])ortant  service  to  the  subject  of  direct  ureteral  catheterization, 
through  his  many  jjublications,  their  important  character,  and  their 
study  of  the  most  minute  details.  A¥e  shall  not  now  describe  his  in- 
strument, as  it  has  already  been  fully  described  on  page  57,  but  shall 
merely  discuss  its  bearing  on  the  subject  of  ureteral  catheterization. 

The  ])atieiit  being  in  the  genupectoral  ])()sition,  the  im|)()rtant  thing- 
is  to  discovei-  the  ureteral  orifices.  Kelly  gives  his  tube  an  obTKiue  in- 
clination of  about  ?A)  degrees,  and  by  making  it  vary  slightly,  and  by 
watching  carefullx ,  the  ureteral  orifices  can  thus  be  seen.  The  ureteral 
cathetei-  is  then  inti-oduced  and  advan.ced  gently  as  far  as  the  kidney. 

The  greatest  difficulty  in  this  procedure  is  that  of  recognizing  the 


26S 


CYSTOSCOPY    AXD    rEETHEOSCOPY 


ureteral  orifice.     This  end  Avill  lie  aided  by  tlie  use  of  an  explorer  or 
searelier.  a  sort  of  fine  stylet.  pro\dded  A\dtli  a  sniootli  mn^  sli.^-fitly 


Fig.   183. — Pawlick's   ureteral   catheters. 


Fig.    184. — Kelh-'s  ureteral   explorer. 


curved  end.  and  a  little  hent  handle  (Fig.  ISrl).  AAiiich  does  not  inter- 
fere with  the  operating  view. 


("ATIIKTKi:iZATl()X    ol"    TIIK    niHTEKS  269 

Evacuation  of  llic  iirliic  is  al-o  a  dirficiill  mallei-.  Kelly  removes 
llic  urine  eitliei'  willi  a  melnllic  calheler  |)i'o\i(|e(|  villi  a  riililxM-  hull), 
or  willi  coUoii  lampoiis.  These  iiiani])ulalioiis  do  not  (•()iii])i('t('l y  iv- 
iiioNc  the  ui-ine,   howcNcr,  and  iKM-cssitate  a  eonsidei-altic  loss  of  time. 

Ilowexcr  Ihis  may  he,  we  must  see  1lie  skill  an-l  dexterity  Avitli 
wliicli  Kell\-  liimseir  cal  liele|-izes  the  reinaie  ui-elei-.  hefore  \ve  can 
un(h'rsland  how  cNcn  willi  his  sk'ill  this  procedui'e  can  he  of  any  vahn'. 

REFERENCES 

idiiiiifi'lil :      I)i:'   Kii(1()skn])ie  der   lliiviuiilirc    uml   ]'.l:isc,    Dcntsclic   ('hiiur^ic    vnn    I'.illiolli    iiii<1 

Lueckc,  1881,  No.  51,  special,  p.  211. 
-Pawlick:     Zentralbl.   f.   Gyiiak.,   1896. 
aPawlick:      Rev.  de  oyiii'o.  et  de  r-hiv.  al.d.,  Rept.-Oot..  1807.  pp.   787-823. 

TECHNIC  OF  URETERAL  CATHETERIZATION  WITH 
LUYS'  DIRECT  VISION  CYSTOSCOPE 

The  operative  teclmic  of  my  cystoscope  lias  already  l)eeri  described 
(see  page  229).  It  is  therefore  not  necessary  to  repeat  it  at  this  time. 
The  patient  being  in  the  inclined  position,  and  the  cystoscope  in  the  air- 
distended  bladdei',  the  first  step  is  to  iind  the  ureteral  orifices. 

Finding  the  Ureteral  Orifices. — AVhile  it  is  qnite  easy  for  the  ex- 
perienced, the  search  for  the  ureteral  orifice  is  nmch  more  difficnlt  for 
the  beginner.  One  ninst  know  the  exact  topography  of  the  bladder, 
■which  takes  on  a  rather  special  significance  nnder  the  action  of  the  in- 
clined position  of  the  pelvis. 

The  most  valnable  gnide  in  finding  the  ureteral  orifices  immedi- 
ately, is  this:  The  cystoscopic  tube  is  inserted  into  the  bladder  up  to 
the  posterior  wall.  AVhen  the  tube  is  ^vlthdl•a^\•n  horizontally,  we  see 
first  only  the  posterior  Avail,  because  the  fioor  of  the  l)ladder  lies  di- 
rectly under  tlie  tube;  withdrawing  the  tube  still  further,  the  fioor, 
very  deep  at  first,  now  comes  into  vi(^w  suddenly.  There  is  a  very 
clear-cut  line  of  deuuircation  at  this  point,  which  is  very  easy  to  ob- 
serve; and  it  is  precisely  when  tlii<  uioment  is  reached  that  one  can  be 
certain  of  being  dirt'ctly  u])ou  the  inlei-ureteral  ligament.  Conse- 
quently, by  slightly  inclining  the  tube  to  the  right  or  to  the  left,  the 
corresponding  ureter  will  be  found. 

Let  us  hasten  to  add  that  the  most  common  faull  in  this  procedure 
usually  consists  in  inclining  the  tul)e  too  much  1o  one  side.  As  a  gen- 
eral rule,  it  may  be  said  that  the  orifices  are  not  far  from  the  me(lian 
line,  but  the  tendency  is  to  get  too  far  away  from  them. 

AVhile  the  discovery  of  the   ureteral   orifices    is  a   simple  enough 


PLATE  XVII 

Fig.  1. — Urethral  aspect  of  polypi  on  the  neclc  of  the  bladder.  These 
polypi  could  not  be  recognized  except  through  the  direct  vision  cysto- 
scope,  by  the  aid  of  which  both  urethral  and  vesical  aspects  of  the  blad- 
der neck  can  be  examined. 


PLATE  XVII 


CATIIKTKIMZATIOX    OK    TIIK    riM'/PKn.S 


271 


mallei'  iiiidci-  normal  and  nsual  condilions  with  llii-  pi-of-c'durc  i1  is 
allo.H'cl  licr  dilTcrcnl  in  acnic  ('_\>lilis,  oi'  w  lien  llif  vesical  \\;dl  i>  uranu- 
lai",  OI"  iiillamcd,  and  hiccds  a1  llic  slii^lilcsl  conlacl,  oi'  w  licii  fnaiiipula- 
iion  is  very  ])ai!irul. 

(\'riaiii  ral  licr  special  itroccdiircs  will  llicn  hccomc  ncccs-.-irx-: 
F'irsl,  ii  \\ill  Ix'  necessary  to  conlrol  llie  pain.     Idie  l>o\\c!s  liaN'inc" 


(^'  oflr,  ^^?  2 


Fig.  185. — Finding  the  ureteral  orifices  with  I,uys'  direct  vision  cystoscope,  the  bladder  being  di- 
lated under  the  influence  of  the  inclined  position.  The  endoscojiic  tube  is  first  introduced  into  the 
lundus  of  the  bladder,  in  first  position;  then  it  is  gradually  withdrawn  to  second  position;  suddenly,  the 
fundus  reappears  toward  the  tube;  it  is  now  at  tlie  inlerureteral  ligament,  which  is  a  most  valuable 
guide.  All  that  is  now  necessary  is  to  incline  the  tulie  laterally  somewhat  and  place  it  in  third  position, 
and    the    ureteral    orifice    will    surely    be    found. 


l)oen  einplied,  tlie  patioiit  is  .i^-iveii  a  ix^taiiied  enema,  lialf  an  liour  l>efore 
the  examination,  consistini;'  ol'  one  or  Iwo  urams  of  an1ii\\iin  and 
twelve  drojjs  of  laudanum.    Sometimes  this  is  iiisul'licieiit ;  the  Madder, 


272 


CYSTOSCOPY    AND    URETHROSCOPY 


being  liiglily  sensitive,  rebels  at  tlie  slightest  contact,  tbns  making  an 
examination  extremely  difficnlt  if  not  altogether  impossible.  ^In  tliese 
conditions  it  may  become  necessary  to  resort  to  hypodermic  injections 
of  morphine  or  of  scopolamine,  as  has  been  recommended  by  Terrier. 


Fig.   186. — View   of  the   left   ureteral    orifice   magnified   by   the   lens   of   Luys'    direct  vision   cystoscope. 

I  have  had  occasion  to  apply  the  la.st  mentioned  procedure  with 
great  success  in  the  service  of  J.  Ij.  Faure,  in  a  patient  of  Lapointe's. 
The  bladder  was  particularly  painful,  but  with  this  method  of  anesthe- 
sia, it  was  possible  to  catheterize  the  ureters. 


CATii  i;'n;i;i/,A'i'iox   oi'  ■iiii-;   iiiktkks  273 

fSccoiid,  it  will  ol'tcii  lie  iicccssni'X'  to  conli-ol  tlic  Wlccdiii^-  of  llu,'  ves- 
ical iiiucosa.  Wiu'ii  tlic  cystitis  is  xvvy  pi-oiioiinccd,  tlic  vesical  wall 
bleeds  at  llic  slig'litest  contaet,  and  the  hlood  completely  ol)seures  the 
field  of  N'isioii;  it  is  then  im])0ssi!)le  in  sj)ite  of  llie  re])eated  use  of  eottoii 
tampons,  to  distiii<j,iiisli  the  details  of  the  vesical  imicosa  cleai'ly.  In 
these  eii'cumstances  it  may  ])e  extremely  difficult  to  lind  the  iii'eteral 
oi'ifices. 

A  veiy  simple  pi'oeedure  will  overcome  these  difficnlti(\'<.  Ifavinfi' 
stanched   the  l)lood   Avitli   a  cotton  tampon,   it  is  usually  sufficient  to 


Fig.    187. — IJirect    catheterization    of   the    left    ureter.      When    the    ureteral    orifice   has    been    well    located,    a 

ureteral    catheter   enters   the   ureter   easily. 

apply  to  the  bleeding  point,  another  tampon  saturated  with  a  1:1000 
adrenaliii  solution,  in  order  to  make  certain  after  some  moments,  that 
all  bleeding  has  ceased.  Great  care  is  necessary,  however,  for  this  stop 
to  have  a  proper  effect.  It  is  absolutely  essential  th.at  the  adrenalin'he 
placed  only  on  the  actual  bleeding  point;  this  agent  i^  effective  only 
Avhen  applied  to  the  bleeding  si:)ot. 

Third,  the  uretei'al  orifice  may  not  be  located,  although  the  extrem- 
ity of  the  cystoscoi)ic  tube  has  been  directed  exactly  upon  the  point 
which  should  normally  correspond  to  the   uretei'al   orifice.     Tn  such  a 


274 


CYSTOSCOPY    AND    URETHROSCOPY 


5^ 


\\*o 


Fig.   ]8S. 


Fig.   189. 


Fig.    188.— Small    catheter   provided    witli   a    metallic    stylet    for    direct    catheterization    of   the    ureter    in    the 

female. 

Fig.   189. — Ureteral    catheter    devised    especially    for    direct    catheterization    of    the    ureter. 


("ATM  i';ri:i;i/.\'ri().\   (»i'  ■nii;   iiiKTioits 


275 


case,  it  is  well  lo  slrdcli  llic  xcsical  iiiiicosa  hy  (|('i)r('ssin,u'  i1  willi  1!k' 
li|»  of  1  lu'  cysloscopic  I  iihc  In  I  his  iiiaiiiicr,  a  u  id  era  I  (Hilicc  is  |-c\('al<'<|. 
wliicli  was  liiddcii  hchiiid  a  fold  of  I  he  iiuicosa,  and  was  lliiis  inacccssihlc 
at  llic  lirsl  cxaiiiiiial  ion. 

Aiiotlicr  ])i'()('('diir('  is  to  wait  for  tlic  ureteral  ojaciilalion,  wliicli 
acts  as  a  i2,uid('  lowai'd  llie  source  of  the  jet;  in  this  way,  the  ureteral 
meal  us  can  ol'len   he  locatcMl. 

l^'ourlli,  lliei-c  ai'e  eases  in  wddeli,  in  S])i1e  of  all  ])alienec  ;ind  cai'O, 


V 


A  \     m/  ffSi 


Fig.   190. — Direct   ureteral   catheterization    in   the    male. 


the  ojoerator  does  not  succeed  in  locating'  the  ureteral  orifice.  In  these 
assuredly  rare  cases,  the  method  reconnnended  hy  Voelcker  and  Joseph, 
for  prismatic  cystoscopy  should  be  adopted.  Ten  minutes  before  the 
examination,  a  subcutaneous  injection  of  4  c.  c.  of  a  sterile  4  per  cent 
solution  of  indio'ocariniiie  is  given.  The  urine  is  11ms  coloied  dark  blue 
at  the  end  of  iiftecMi  minutes,  and  at  the  moment  of  ejaculation  it  is  eas)^ 
to  see  tlie  exact  point  at  wliicli  the  colored  urine  cmei'ges;  namely,  the 
ureteral  oritice. 


276  CYSTOSCOPY    AXD    TRETHROSCOPY 

Ureteral  Catheterization  (Luys). — When  tlie  ureteral  orifice  has 
been  located,  it  is  well  to  place  the  lower  margin  of  the  CYstosco^ic  tu])e 
directly  in  contact  witli  it  (Plate  XIII,  Fig.  2).  The  cystoscope  is  then 
fixed  firmly  with  the  left  hand,  while  the  sterile  ureteral  catheter  is 
introduced  with  the  right.  The  catheter  is  directed  along  the  floor  of 
the  tube  and  quite  naturally  enters  the  ureteral  orifice  in  the  easiest 
possible  manner,  progressing  as  far  as  the  pehis  and  kidney.  This 
entire  iDrocedure  appears  to  be  extremely  simple  and  remarkably  easy 
of  performance. 

The  sole  jDrecaution  to  l)e  taken  is  to  liaYe  a  Yery  straight  and  rigid 
ureteral  catheter.  When  the  catheter  is  new,  this  condition  is  usually 
present;  but  after  it  has  been  used  some  time,  it  becomes  soft  and  it 
no  longer  has  the  necessary  rigidity  to  adYance  beyond  the  ureteral 
meatus. 

In  these  circumstances  we  place  a  fine  stylet  of  wire  mthin  the 
lumen  of  the  catheter.  This  stylet  must  not  extend  to  the  end  of  the 
catheter  in  order  that  the  catheter  tijD  shall  be  yielding,  and  not  danger- 
ous, still  sufficiently  rigid  so  that  it  Y\'ill  not  strike  the  ureteral  orifice 
and  bend  on  itself.  Once  the  tip  of  the  catheter  lias  engaged  in  the 
ureter,  the  stylet  is  withdrawn  and  the  catheter  is  adYanced  into  the 
ureter  as  far  as  the  pelYis,  if  so  desired.  The  handle  of  the  cystoscope 
is  withdrawn,  and  with  it  comes  the  cystoscopic  tube  proper. 

For  ureteral  catheterization  in  the  female,  we  use  a  short  straight 
ordinary  catheter.  No.  5,  6,  or  7,  which  is  usually  sufficient  for  collecting 
the  separate  urines,  or  for  examination  of  the  lower  extremity  of -the 
ureter. 

I  haYe  deYised  a  special  ureteral  catheter  for  the  male,  so  as  to 
obYiate  the  use  of  the  stylet.  The  catheters  most  commonly  used  cor- 
resjDond  to  Xos.  7,  8,  or  9,  Charriere;  their  tips  are  cut  Ijlunt  and  haYe 
two  eyes  laterally.  Their  tip  is  soft  and  flexible  for  a  distance  of  one 
centimeter;  then  for  about  fifteen  centimeters  they  are  of  a  little  harder 
substance,  which  is  more  resistant  and  capable  of  furnishing  sufficient 
I'igidity.  The  rest  of  the  catheter  is  flexible  and  ends  in  a  broad  funnel, 
to  which  the  cannula  of  a  syringe  can  be  attached.  These  catheters 
penetrate  Yery  readily  into  the  ureter  and  facilitate  laYage  of  the  pelYis.. 

In  actual  practice,  howcYer,  these  catheter  models  are  not  indis- 
pensable, and  in  the  Yast  majority  of  cases,  CYcn  in  the  male,  ordinary 
ureteral  catheters  can  be  used,  proYided  they  haYe  a  fine  stylet  which 
is  well  lubricated  and  particularly  smooth  and  clean.  Oj^erating  in 
this  way,  ureteral  catheterization  really  becomes  Yery  easy,  and  with 
experience,  can  be  performed  Yery  rapidly. 

The  picture  of  the  ureteral  orifices  seen  with  the  direct  Yiew  cysto- 


CATHETERIZATION    OF    THE    URETERS  Z(  ( 

scope  is  so  clear  and  distinct,  tliat  general  surgeons  and  obstetricians 
who  do  not  specialize  in  urinary  surgery,  readily  succeed  even  after  the 
(irst  allciiipl.  'IMius  Tyiw,  who  liad  never  examined  the  bladder  with  a 
cystosc()])e,  and  had  never  catliclerized  the  ureters,  was  able  to  catheter- 
ize  at  the  very  first  trial,  Tn  the  same  way,  Lapointe,  a  surgeon  in  the 
hospitals  of  Paris,  also  wrote  me  on  August  11,  lOOG,  that  he  liad 
catheterized  both  ureters  in  a  normal  bladder  with  my  instrument  with 
the  greatest  ease. 

Pierre  Delbet  reported  to  the  Surgical  Societ}^^  "The  ureteral 
orifices  are  readily  seen;  and  as  the  ureteral  ejaculation  takes  place  in 
an  empty  bladder,  distended  only  by  air,  each  drop  of  urine  is  seen  with 
extraordinary  clearness.  In  a  case  in  which  it  was  not  at  all  necessary, 
I  was  tempted  childishly  to  insert  a  catheter  into  the  ureter  simply  for 
the  pleasure  of  doing  so,  and  it  was  done  just  as  easily  as  insertng  a 
probe  into  a  cutaneous  fistula." 

I  therefore  believe  that  it  is  infinitely  preferable  to  catheterize 
with  the  direct  cystoscope,  than  across  a  cystotomized  bladder,  as  has 
been  suggested  by  Legueu.^  One  can  always  see  better  in  the  closed 
bladder  with  my  cystoscope  than  in  the  open  bladder,  without,  at  the 
same  time,  assuming  the  risk  of  an  operation. 

The  following  are  reports  of  a  few  cases  in  which  this  method  Avas 
especially  useful: 

Case  1. — Left  Pyonephrosis:  Examination  of  the  Separate  Urines  Showed  an  Absence 
of  Left  Kidney  Function;  Direct  Catheterization  of  the  Left  Ureter  Showed  the  Exact,  Site 
of  the  Obliteration. 

A  woman,  aged  forty  years,  entered  the  service  of  Beurnier,  at  Tenon  Hospital,  in  No- 
vember, 1904.  She  presented  a  large  tumor  in  the  left  hypochondrium ;  it  was  movable 
transversely,  but  very  little  vertically,  and  was  suggestive  of  a  tloating  kidney.  The  urine 
was  clear,  and  bladder  capacity  excellent.  The  previous  history  showed  attacks  of  nephritic 
colic  for  a  long  period,  and  always  on  the  left  side.  Vaginal  examination  showed  that  the 
inferior  extremity  of  the  left  ureter  was  distinctly  painful. 

Endovesical  separation  of  the  urine  on  November  23,  made  by  me,  gave  the  following 
data:  On  the  right  side,  clear  urine,  with  distinct  ureteral  ejaculation;  on  the  left  side, 
not  a  drop  of  urine.  •  The  conclusion  was  evident  that  the  entire  clear  urine  was  being  fur- 
nished by  the  right  kidney,  and  that  the  left  kidney  had  no  functional  value  because  its 
ureter  was  obliterated. 

In  order  to  determine  the  exact  site  of  the  olistructioii.  I  catheterized  the  left  ureter 
with  my  cystoscope,  with  the  aid  of  Eabinovitch,  intern  of  the  service,  on  November  29. 
The  right  ureteral  orifice  was  absolutely  normal;  the  left  orifice,  on  the  contrary,  was  red, 
puffy,  and  surrounded  by  a  very  pionounced  inflammatory  zone.  Nevertheless,  this  orifice 
was  immediately  catheterized  with  the  greatest  ease,  as  soon  as  it  was  located.  The  catheter 
penetrated  easily  into  the  ureter,  but  was  obstructed  at  a  point  about  2-i  centimeters  from 
its  orifice,  and  it  was  impossible  to  advance  it  any  further.  It  bent  and  twisted  under  the 
eye  in  the  cystoscopic  tu1)e,  and  made  no  further  progress.  It  was  noted  that  no  urine  came 
through  the  orifice,  not  even  when  asj^iration  was  attempted  at  the  free  end  of  the  catlieter. 
The  action  of  the  piston  proved  that  there  was  an  actual  vacuum  in  the  lumen  of  the  catheter ; 
the  latter,  on  later  examination,  was  found  perfectly  patent. 

We  were,   therefore,   dealing   with   an   obliteration  of   the   left   ureter   near   the  kidney. 


278 


CYSTOSCOPY   AND   URETHROSCOPY 


Oeiri. 


anastomosis,    followed    by    seconaarj    i    '^       .u^    5  iV,p    interior    of    the   oelvis    with    two    orifices;    one    is   the 


CATHETERIZATIOISr    OF    THE    URETERS  279 

This  diagnosis  was  confirmed  at  operation  on  the  following  day.  Beurnier  performed  left 
lumbar  nephrectomy  and  found  a  closed  pyonephrosis;  the  ureter  was  completely  obliterated 
by  the  perinephritis.     The  specimen  is  preserved  in  my  private  collection. 

Case  2. — Intermittent  Hydronephrosis :  Separation  of  the  Urines  during  the  Period  of 
Betention;  Vreteropyeloneoslomy ;  Direct  Ureteral  Catheterization ;  Nephrectomy. 

On  Dec.  8,  1904,  Tuffier  asked  me  to  effect  separation  of  the  urines  in  a  woman  twenty- 
five  years  of  age,  who  had  entered  his  service  at  Beaujon  Hospital  two  days  previously.  She 
complained  of  extremely  severe  pain,  resembling  renal  colic,  and  always  on  the  left  side. 
These  painful  attacks  began  nine  years  previously,  at  the  age  of  sixteen.  During  these 
attacks,   a  large  tumor  formed  in  the  left  hypochoudrium,  while  at   the   same  time,   urinary 

Ordinary  Diet 
right  kidney  left  kidney 

From    10   to    10:45   A.M. 

V=155  c.c.  V  =  27  c.c. 

A  =  -1-21°  A  =  -0.24° 

From  2  to   2:45   p.m. 

V  =  150  c.c.  V  =  25  c.c. 
A  =  -0.78°  A  =  -0.26° 

From  4  to  4:30  p.m. 

V=z  60  c.c.  V=30  c.c. 

A  =  -1-12°  A  =  -0.20° 

Partial  Milk  Diet 
12  to  12:45  Noon 

V  =  1C0  c.c.  Vz=30  c.c. 
A  =  -0.85°  A  =  -0.21° 

1  to  1:45  P.M. 

V  =  96  c.c.  Y  =  27  c.c. 
A  =  -0.86°  A  =  -0.25° 

4  to  4:45  P.M. 

V  =  105  c.c.  V  =  32  c.c. 
A  =  -0.86°                                    A  =  -0.22° 


V  =  Volume.     A  =  Freezing  point   (in   Cryoscopy). 

secretion  diminished  in  quantity.  This  phenomenon  lasted  several  hours,  at  times,  several 
days.  The  attack  usually  ended  with  a  profuse  emission  of  urine,  cessation  of  the  pain  and 
disappearance  of  the  abdominal  tumor.  The  passage  of  a  stone  was  never  observed.  The 
urine  was  continually  clear,  and  there  was  never  any  trace  of  blood. 

When  I  first  saw  her,  she  was  in  the  midst  of  one  of  these  attacks.  A  large  tumor  was 
felt  in  the  left  hypochoudrium,  movable,  kidney-shaped,  and  strongly  suggestive  of  a  float- 
ing kidney.  The  urine  collected  with  a  catheter  was  absolutely  clear.  Tlie  urine  separator 
was  introduced  easily  and  left  in  place  for  fifteen  minutes;  the  right  side  showed  rhythmic 
and  regular  emissions,  although  somewhat  slow,  for  the  patient  had  taken  nothing  during 
the  entire  morning ;  on  the  left  side,  on  the  other  hand,  not  a  single  drop  of  urine  was  passed 
during  that  entire  period.     An  assistant  who   attempted  to   push  the  tumor  upward  toward 


280  CYSTOSCOPY    AND    URETHROSCOPY 

the  diaphragm,  met  with  no  success.     When  an  attempt  was  made  to   grasp  the  tumor  be- 
tween the  two  hands,  the  same  negative  result  followed. 

The  diagnosis  was  therefore  very  evident, — a  closed  uronephrosis.  Tuffi^-  operated 
immediately  after  this  examination.  The  leic  kidney  was  exposed,  but  as  it  was  too  large 
to  be  delivered  into  the  wound,  it  was  first  punctured;  more  than  half  a  liter  of  fluid  escaped. 
The  pelvis  was  then  freed  and  was  found  enormously  dilated,  and  the  ureter  which  followed 
it  was  small  and  kinked  near  its  origin.  Tufifier  did  a  pyeloureteral  anastomosis,  connecting 
the  lower  end  of  the  pelvis  with  the  ureter  (Fig.  191).  Tlie  operation  was  finished  in  the 
usual  manner. 

For  eight  days  the  patient  progressed  very  nicely,  but  a  lumbar  fistula  then  formed, 
and  almost  all  the  urine  was  eliminated  through  the  lumbar  wound.  The  dressings  were 
soaked  with  urine  continually.  To  remedy  this  condition,  I  catheterized  the  left  ureter  on 
December  27,  with  great  facility,  and  the  ureteral  catheter  was  left  in  sitit,  for  two  days. 
On  Januai-y  3,  1905,  the  patient  was  in  good  general  condition.  The  lumbar  wound  was 
almost  closed  and  no  urine  passed  through  it. 

During  the  forty-eight  hours  in  which  the  catheter  was  left  in  the  ureter,  the  separated 
urines  were  examined  chemically  by  Maute,  and  showed  that  the  functional  value  of  the 
left  kidney  was  almost  nil.     The  table  on  page  279  shows  the  analyses. 

In  view  of  these  findings,  which  demonstrated  a  complete  functional  insufficiency  of 
the  left  kidney,  Tuffier  decided  to  perform  nephrectomy.  This  proved  to  be  very  difficult 
because  of  the  strong  adhesions  that  had  been  formed.  The  renal  parenchyma  was  found 
extremely  diminished;  the  pelvis  was  dilated  to  double  the  size  of  the  kidney.  A  probe 
introduced  into  the  lower  part  of  the  ureter  penetrated  directly  into  the  pelvis  across  the 
newly  formed  opening;  at  the  side  of  this  new  opening,  the  former  ureteral  orifice  was 
seen,  normal  in  size   (Fig.  191). 

By  means  of  a  minute  dissection  of  the  entire  ureteral  canal,  it  was  possible  to  follow 
the  canal  from  its  origin  at  the  pelvis  up  to  the  ureteral  anastomosis,  and  it  was  found 
twisted  upon  itself  in  the  form  of  a  loop.  A  probe  could  not  be  passed  from  the  normal 
ureteral  orifice  to  its  lower  extremity  because  it  was  stopped  at  the  uretero-pyelo-auastomosis. 

From  this  case,  therefore,  we  may  draw  these  conclusions: 

1.  Separation  of  the  urines  demonstrated  that  the  kinked  ureter  did  not  allow  the 
urine  to  pass  through,  for  not  a  drop  of  urine  had  been  collected  from  the  left  side. 

2.  The  uretero-pyelo-anastomosis  did  not  reestablish  the  urinary  flow  completely,  be- 
cause a  lumbar  fistula  developed  eight  days  later. 

3.  Ureteral  catheterization  opened  a  channel  for  the  urine,  for  the  lumbar  fistula 
healed  under  this  treatment.  Besides,  the  analysis  of  the  urine  from  the  affected  kidney 
collected  for  a  period  of  twenty-four  hours  showed  that  the  kidney  had  no  functional  value 
whatever. 

4.  Nephrectomy  demonstrated  that  although  the  ureteral  lumen  was  absolutely  patent 
in  its  entire  course,  from  its  origin  at  the  pelvis  to  its  new  ureteral  orifice,  nevertheless  it 
flowed  incompletely  through  the  ureter  because  the  pelvis  was  found  full  of  urine  at  the 
second  operation. 

The  patient  left  the  hospital  on  January  29,  1905,  cured.  Tlie  specimen  is  preserved 
in  lily  private  collection. 

Case  3. — Tiiberculosis  of  the  Higlit  Kidney:  Recognised  iy  the  Luys'  Separator  and 
Confirmed  hy  Direct  Ureteral  Catheterisation. 

A  woman,  aged  twenty-eight  years,  was  brought  to  me  on  November  30,  1905,  by 
Nogues,  who.  wrote  the  following  report  of  the  case: 

She  had  complained  for  over  a  year,  of  frequent  urination,  with  pain  and  slight 
hematuria  at  the  end  of  the  act.  The  urine,  examined  by  Nogues,  contained  numerous 
tubercle  bacilli.     Vesical  capacity  80  c.c.     She  voided  six  to  eight  times  during  the   night. 


('ATM  i'yii;i;i/A'i'i(».\   oi'  tiik   ri;K'i'Ki;s  281 

Tlici-c  was  iin  jiaiii  in  llic  kidiicv  ri'^iinii,  nui'  any  incir;isc  in  llic  si/.c  <<{'  the  l<iiini'y.  I'imlo- 
vcsical  scpaial  inn,  nimlc  by  Noyiirs  will:  l.iiys'  separator,  hust:  tliis  picture:  On  the  left, 
ricar  urine;  on  IIh'  li^lil,  more  al)nn(lan1  urine,  paler,  lurliid,  and  tubercle  bacilli  pix-soiit. 
Indirect  cysloscoiiy  showed  a  ninanal  liladih'r.  1 1  ow  i'\  cr.  llie  riylit  ureteral  orifiee  is  not 
sullicienlly  visilile  (o  nu',  1o  ni;ike  il  woilii  while  (u  atleni|il  ral  liel  eri/.at  ion.  ( 'onscfjuent  ly  the 
jialiiud  was  taken  In  laiys,  who  easily  inli'odui'ed  a  eathelei'  inio  the  ri;;lit  urelei-  with  his 
direct  cystoscope,  in   the   presence  uf  the  writer. 

A  flow  of  pus  showed  I  hat  the  catheter  had  penetrated  into  the  purulent  poclvct  of  the 
rii;li(  kidiM'y,  and  thus  had  accomplished  its  object.  Subsequently,  the  patient  was  oper- 
ated ou  at  Necker  Hospital,  and  recovered  rapidly  witliout  untoward  incident.  Nephrectomy 
revealed  three  pus  cavities,  thus  fully  verifying  the  diagnosis  made  by  the  cystoscope  and 
catheter. 

Case  4. — Eight  Pyonephrosis  and  Amite  Cystitis:  Urinary  Scimration  Impossible,  Excrpt 
by  Direct  Ureteral  Catlieterisation. 

I  was  called  upon  to  cathcterize  the  ureters  in  a  woman,  aged  thirty-five  years,  in  the 
service  of  Hartmann,  at  Lariboisiere  Hospital,  on  April  17,  190o.  She  showed  clinical 
symptoms  of  right  pyonephrosis.  The  kidney  was  palpaljle,  and  the  right  ureter  was  also 
felt  very  much  enlarged.  But  inasmuch  as  the  left  kidney  was  also  palpable,  but  to  a 
lesser  degree,  segregation  of  the  urines  seeined  indicated.  The  symptoms  of  cystitis  were 
so  acute,  however,  that  an  cndovesical  separation  of  the  urines  could  not  be  considered.  The 
urine  was  turbid,  with  a  purulent  precipitate,  and  in  addition,  the  urine  was  voided  every 
fifteen  minutes,  with  hematuria  every  two  or  three  days.  Catheterization  by  means  of  the 
indirect  (prismatic)  cystoscope  was  also  out  of  the  question,  because  of  the  very  small 
vesical  capacity. 

With  the  aid  of  the  direct  cystoscope,  I  catheterizcd  the  riglit  ureter  in  a  few  minutes 
without  any  difficulty;  the  endoscopic  tube  having  been  withdrawn,  the  right  ureteral  cath- 
eter remained  in  situ,  and  a  Nelaton  catheter  was  introduced  into  the  bladder.  Tliis  sepa- 
ration of  the  urine   gave  the  following  results: 

The  ureteral  catheter  which  drained  the  right  kidney  gave  an  absolutely  purulent 
milky  white  fluid;  while  the  catheter  in  the  bladder,  which  collected  the  urine  from  the 
left  kidney,  produced  urine  that  was  bloody,  but  not  quite  so  thick  as  the  urine  from  the 
right  side. 

Case  5. — Uretcro-pyclo-a nastomosis :  Direct  Catlicterizatioii  of  the  Operated  Ureter 
Showed  Distention  of  the  Pelvis. 

A  woman,  having  ])een  subjected  to  a  left  uretcro-pyelo-nnnstomosis  by  Robino:ui.  in 
the  service  of  Tutfier,  for  symptoms  of  uronephrosis,  later  developed  a  lumbar  tislrda.  On 
May  2,  1905,  in  order  to  correct  the  improper  drainage  of  the  new  ureteral  mouth,  Rolnneau 
asked  me  to  catheterize  the  left  ureter.  Direct  catheterization  was  performed  easily,  and 
demonstrated  that  the  pelvis  was  considerably  dilated  and  had  a  capacity  of  about  150  e.c. 

Case  6. — Attacks  of  Left  Hydronephrosis:  Catheterization  of  the  Left  Ureter  Sitff- 
gcsting  the  Presence  of  a  Ureteral  Calcuhis. 

A  woman,  aged  twenty-five  years,  entered  tiie  Tenon  Hospital,  in  the  service  of 
Rochard,  in  March  1905,  complaining  of  violent,  painful  attacks  in  the  left  hypochondrium, 
Avhich  recurred  frequently  at  intervals  varying  from  four  to  fifteen  days.  These  attacks 
first  appeared  four  years  previously.  During  the  crises.  :r  inass  appeared  at  the  left 
hypochondrium  coincident  with  a  considerable  decrease  in  the  (piantity  of  urine  passed. 
A  preliminary  examination  by  direct  cystoscoiiy,  on  March  11,  showed  the  right  ureteral 
ejaculations  very  clearly,  but  on  the  left  side,  on  the  contrary,  although  the  orifice  was 
distinctly    visible,    not    a,    drop    nl'    urine    was    ejaculaleil. 

The   left   kitluey   was   clearly    felt   ou    bimanual   palpation;    it    was   easily   reducible   and 


282  CYSTOSCOPY    AND    URETHROSCOPY 

also  quite  paiuful.  On  Marcli  24,  after  many  attempts  at  catheterization  of  the  left  side, 
a  ureteral  catheter  No.  6,  was  easily  introduced,  with  some  interruptions  at  first.  With 
the  aid  of  a  stylet  inserted  into  the  lumen  of  the  catheter,  it  penetrated  ^  far  as  the 
pelvis  J  the  capacity  of  the  latter  proved  to  be  about  25  c.c.  While  the  catheter  was 
being  withdrawn,  a  sensation  of  friction  was  distinctly  felt;  this  justified  the  suspicion 
of  a  ureteral  calculus.  The  patient  was  sent  to  the  radiographic  department,  but  un- 
fortunately, the  case  could  not  be  followed  up  thereafter. 

Case  T.—^The  Bight  Kidney  Alone  Clinically  Affected:  Intravesical  Separation  and 
Catheterization  of  the  Ureters  Shoiv  Both  Kidneys  Affected,  a  Contraindication  to  Bight 
Nephrectomy.     (Courtesy  of  Lapointe.) 

M.,  a  woman,  aged  thirty-two  years,  was  referred  to  Lapointe,  at  Tenon  Hospital, 
on  May  10,  1905,  by  Barbellion,  who  had  been  treating  her  for  several  months  for  cystitis 
and  enlargement  of  the  right  kidney.  The  patient  had  had  trouble  with  her  right  kidney 
from  infancy,  but  apart  from  these  symptoms,  she  had  not  had  any  previous  serious  ill- 
ness. Several  cervical  scars,  however,  resulting  from  an  old  suppurative  adenitis,  were 
observed.  It  was  also  noted  that  her  father  had  died  of  pulmonary  tuberculosis  at  the 
age   of   forty. 

During  pregnancy,  eighteen  months  previously,  she  complained  of  frequent  and  pain- 
ful micturition.  At  the  same  time,  the  pains  in  the  right  kidney  increased  considerably 
and  the  patient  noticed  a  swelling  on  the  right  side.  This  mass  alternately  increased  and 
decreased  coincidently  with  the  increase  and  decrease  of  the  painful  manifestations.  From 
that  time   on,  the   urine  became  turbid,   but  without  any  hematuria. 

Late  in  1905,  Barbellion  began  to  treat  the  bladder,  which  was  very  sensitive,  by 
instillations  of  silver,  and  subsequently  with  guaiacol  oil  and  gomenol.  Under  this  treat- 
ment, the  urinary  frequency  and  the  pain  diminished,  but  the  kidney  remained  large  and 
sensitive. 

When  she  entered  the  hospital,  the  urine  was  turbid  and  purulent,  but  without  blood; 
frequency  every  hour.  The  bladder  was  extremely  sensitive  to  contact  and  to  distention. 
Its  capacity  was  only  about  30  c.c.  On  palpation,  the  right  kidney  was  found  as  large  as 
both  fists,  lowered  in  position,  irreducible,  painful  on  pressure   and  fluctuating. 

The  vesical  portion  of  the  right  ureter  Avas  thickened  and  painful  on  vaginal  e;xamina- 
tion.  The  left  kidney  was  not  palpable.  To  complete  the  diagnosis  and  determine  the  ad- 
visability of  right  nei^hrectomy,  Lapointe  employed  the  Luys  segregator,  on  May  16,  1906. 
The  instrument  was  badly  tolerated  by  the  bladder,  because  of  the  bleeding  and  the  small 
bladder  capacity  of  30  to  35  c.c.  Nevertheless,  a  quantity  of  urine  was  collected,  suffi- 
cient for  the  chemical  examination,  which  was  made  by  Carrion,  with  the  following  findings: 


RIGHT    KID 

NEY 

Quantity 

3.06  c.c. 

Urea,  per  liter 

3.20  gm. 

Chlorides 

4.68    " 

Freezing  point 

0.54° 

Microscopic 

LEFT   KIDNEY 

3.03 

c.c. 

2.56 

gm. 

4.68 

i  e 

0.52° 

Red  blood  cells,  very  numerous.  Eed  blood  cells  very  numerous 

Leucocytes,  mostly  polynuclear.  Leucocytes  much  less  abundant 

very  numerous. 

Bacteriologic  examination  for  tubercle  bacilli,  negative;  the  urine  of  both  kidneys  con- 
tains bacteria,  some  Gram  positive  and  others  negative.  Most  of  them  are  diplostreptococci 
and  microbes  which  appear  to  be  coli  bacilli.  Two  guinea  pigs  inoculated  on  May  17,  with 
the  right  kidney  urine,  gave  a  negative  reaction  to  tuberculosis. 


CA^rii I'/i'i'iKi/ATiox   (»i'  'I'lii';   ri;i':'i'i';i;s 


283 


AVc  were,  tlicicrdrc,  |ii(ili;i  1  il y  ili';iliii;^  with  ;iii  nidiniiiy  inrrrtnMi;  lnif  llic  cinlnvcsical 
S;0|)ar:iti(ill  of  llir  lllini'  ill.lirulcd  (lllll  tlir  Irl't  kidney,  wliirli  \v;iS  in.t  riil;ii'-c(|.  mid  was 
clinicalh'  imnnal,  iicvrrl  liclcss,  ciiiittcd  sli;;lMly  (dniidy  iiiinc  and  tlial  its  I'atc  of  (diiiiiiiat  ion 
\vas  sliiwcr  tlinn   tliat    of   the    li^lit    kidney,  wliiidi    was  idinienlly   afrocted. 

In  Older  to  coafiiiu  tliesc  unoxpectod  data,  Lapoiiite  attempted  tlic  nietliylenc  l.liio  test 
with  ureteral  catheterization,  aiul  used  the  Luys'  direct  view  cystoscopc  fur  this  purj)OHe. 
After  two  fruitless  trials,  Luys  was  called  in  on  May  2().  To  obtain  relative  tolerance  of  the 
bladder,  Lapointc  had  injected  scoiwlamine-morpliijie  an  hour  before  the  examination,  using 
this  solution: 

Scopolamine    biomohydrate  ^/>   nijj. 

Morphine    ('Idorliydrate  1  eg. 

The  cystoscopc  sliowed  that  the  l)laddcr  was  considerably  affected  with  fungous  growths 
which  bled  on  the  slightest  contact.  The  right  ureteral  orifice  was  seen  in  the  midst  of  the 
fungositics  and  readily  catheterized  with  a  No.  8  catheter.  It  was  much  more  difficult  to 
reach  the  left  ureteral  orifice,  for  at  this  point  the  bladder  bled  profusely.  However,  the 
mucosa  was  thoroughly  dried  by  the  direct  application  of  adrenalin  and  then  the  left  ureteral 
orifice  was  seen,  hidden  at  first,  by  a  fold  of  the  mucosa.  To  see  it  well  it  was  necessary  to 
flatten  down  the  mucosa  with  the  extremity  of  the  cystoscopic  tube,  and  a  No.  7  catheter 
was  then  easily  introduced. 

As  soon  as  the  catheters  were  introduced  into  their  respective  ureters,  a  reflex  polyuria 
was  produced;  the  urine  from  both  sides  was  cloudy.  Previous  to  the  ureteral  catheteriza- 
tion, methylene  blue  was  injected  subcutaneously ;  the  ureteral  catheters  were  left  in  situ 
for  two  hours  and  during  this  period  the  methylene  blue  was  being  eliminated  in  the  form 
of  chromogen,  as  follows: 

RIGHT  KIDNEY  LEFT    KIDNEY 

First  hour  Nothing  Nothing 

Third  half  hour  Distinctly  green  tint  Green  tint  much  less  marked 

Fourth  half  hour  Not  more  pronounced  than  on  right  side 

Not  more  pronounced 

The  urine  passed  by  the  patient  was  first  examined  for  methylene  blue  seven  liours 
after  the  injection  and  the  total  elimination  persisted  for  about  forty-eight  hours.  The 
left  kidney  then  eliminated  less  chromogen  than  the  right  kidney.  The  study  of  the  methy- 
lene blue  elimination  in  both  kidneys,  by  the  aid  of  ureteral  catheterization,  is  in  full  ac- 
cord with  the  results  of  the  chemical  analysis  and  of  cryoscopy  made  on  the  separated 
urines. 

Conclusions. — Segregation  of  the  urines  demonstrated  that  the  left  kidney,  whiili  was 
thought  to  be  healthy,  was  also  diseased,  and  that  its  functional  value  was  even  inferior  to 
that  of  the  right  kidney.  The  baeteriologie  examination,  negative  as  to  tuberculosis,  sug- 
gested a  diagnosis  of  right  hydronephrosis,  the  kidney  having  been  infected  probably  by  au 
intercurrent  cystitis;   also   a  secondary  pyelonephritis  of   the   left  kidney. 

Tlie  pathologic  condition  of  both  kidneys  was  a  distinct  contraindication  tu  n('(ihrcc- 
tomy  of  the  right  kidney,  and  limited  surgical  intervention  to  nephrostomy;  but  the  pa- 
tient left  the  hospital  on  learning  that  her  right  kidney  could  not  be  removed. 

REFERENCES 

iBull.   et.   mem.   Soe.    de   (diii'.   ile    Paris,    l!l05,   session  of    INlarcli    1,    llHii;,    p.    I'll. 
-Legueu :      Du   cat  heterisme    de    I'uvetere    a    travers  la  vessio   ouverte.   Press,   med..    A]iiil    in. 
11)07,  p.  226. 


PLATE  XYlIl 

Fig.  1. — Fhosphatic    calculus    of    the    bladder    pocketed    in    the    inflamed 
mucosa. 

Fig.  2. — Fhospliatic  calculus  of  the  bladder. 

Fig.  3. — Tuberculous  ulcerations  of  the  bladder  seen  with,  the  direct  vision 
cystoscope. 


Fig.  1. 


Fig.  2. 


Fig.  3. 


PLATE  XVIII 


(lATII  KTKIM/ATIOX    OK    T 1 1  I',     IIIKTKUS  2S5 

CHOICE  OF  METHOD  IN  URETERAL  CATHETERIZATION 

IlavJii^'  lliiis  cxaiiiiiKMl  successivclx-  .•ill  llic  niclliods  and  x>i"Ocediii"os 
for  lU'eteral  calliclcrizatioii,  it  is  a\'('II  Io  iii(|uii(;  as  to  wliicli  motliod 
is  to  be  ft'ivcMi  prcfVi-ciicc.  Tt  is  cNidciil  that  catlieterization  is  to  be 
perforiiu'd  cillici'  willi  (rn'cci  oi'  iiidii-cct  A'isioii  cyslosfopy.  Tliese  two 
methods  should  iiol  he  set  ii))  one  a,^ainst  tiu;  ot]!(!r,  as  rivals,  inasniiieli 
as  eac'li  lias  its  own  s]HH'ial  indieations;  one  slionld  supplant  the  other 
under  certain  circumstances. 

Indications  for  Direct  Vision  Cystoscopy  in  Ureteral  Catheterization 

This  method  seems  to  be  the  inelhod  ol;  choice  and  should  l)e  pre- 
ferred above  any  other  under  the  followin<2,'  principal  conditions: 

1.  For  Catheterization  of  a  Normal  Kidney. — When  there  is  a  spe- 
cial indication  for  obtaining  exact  knowledge  of  the  condition  of  the 
ureter  or  of  the  pelvis  of  a  Icidney  thought  to  be  normal,  it  seems  evi- 
dent that  only  the  direct  vision  cystoscope  should  be  emx^loyed  for 
catheterization. 

We  shall  consider  further  on,  the  real  and  absolutely  certain  dan- 
gers of  infection  which  arise  in  ureteral  catheterization  with  the  in- 
direct method.  These  dangers  are,  on  the  other  hand,  reduced  to  a 
minimum,  if  not  obviated  entirely,  with  the  use  of  the  direct  vision 
cystoscojDe. 

With  this  method,  the  ureteral  catheter  emerges  from  the  sterilizer 
and  directly  passes  into  the  ureter,  coming  into  contact  only  with  the 
aseptic  fingers  of  the  surgeon.  The  only  possible  clanger  is  found  in 
touching  the  infected  vesical  wall  with  the  catheter,  if  the  hand  is  not 
exjDerienced ;  but  when  the  end  of  the  cystoscopic  tube  is  directly  in 
contact  with  the  ureteral  orifice,  it  is  a  simple  matter  before  introduc- 
ing the  catheter,  to  touch  up  the  vesical  wall  surrounding  the  ureteral 
orifice  with  a  2  per  cent  solution  of  silver  nitrate,  thus  obtaining  momen- 
tary sterilization  of  the  area.  It  is  thus  made  evident  that  the  dangers 
of  infecting  a  normal  kidney,  if  not  absolutely  nil,  are  at  least  reduced 
to  the  minimum,  wh(>n  oy)erating  with  the  direct  vision  cvstoscope. 

2.  To  Estimate  the  Renal  Function  When  the  Separator  Can  Not 
Be  Used. — The  use  of  the  separator  is  sometimes  impossible;  for  in- 
stance, in  the  presence  of  anatomic  anomalies,  such  as  the  two  cases 
that  I  have  observed,  in  which  the  inferior  wall  of  the  bladder  was 
destroyed  by  vesicovaginal  fistuhu.  This  is  also  true  in  advanced  preg- 
nancy, or  in  cancer,  oi'  libroma  ol*  tlic  uicius,  etc.  Ijikewise  in  cystitis 
Avhicli  is  so  pronounced  lliat  the  exlrciiicly  sensitive  bladder  contracts 
violently  and  pr(>\'en1s  the  I'egular  a])pli('alion  of  the  instrument. 


286  CYSTOSCOPY    AND    URETHROSCOPY 

In  tliese  cases  ureteral  catlieterization  should  be  performed  only 
with  the  direct  vision  cystoscope.  First,  because  the  vesical-  capacity 
is  very  small;  and  second,  because  the  difficulty  of  obtaining  the  re- 
quired transparent  bladder  medium  makes  indirect  cystoscopy  almost 
impossible. 

What  a  difference  there  is  in  operating  A\itli  the  indirect  cysto- 
scope, when  pus  and  blood  constantly  obstruct  the  visual  field,  and  on 
the  other  hand,  with  direct  cystoscopy,  with  which,  after  tamponing, 
the  operation  is  performed  on  a  dr}^,  clear  mucosa,  upon  Avhich  one 
can  work  with  security,  with  system  and  Avitli  success! 

In  a  particularly  difficult  case,  I  obtained  a  splendid  result.  In  the 
service  of  Souligoux,  at  Tenon  Hospital,  I  saw  a  young  woman,  aged 
twenty-four  years,  who  had  a  large  tumor  on  the  riglit  side  and  seemed 
to  be  suffering  pain  on  the  left  side.  The  urine  was  extremely  bloody, 
the  vesical  capacity  Avas  100  c.  c,  and  it  Avas  almost  impossible  to  obtain 
a  transparent  medium.  NotAvithstanding  these  difficulties,  on  NoA'-em- 
ber  8,  1907,  I  AA^as  enabled  to  catheterize  the  left  ureter,  the  only  one 
Adsible,  in  the  presence  of  Lagane,  intern  of  the  hosi)ital. 

Gauthier,  of  Lyons,  Avas  also  able  to  locate  and  catheterize  one 
ureter  in  a  tuberculous  bladder  AAdiich  Avas  completely  ulcerated  and 
bleeding  on  the  slightest  contact,  and  Avith  a  capacity  of  40  c.c.  In  an- 
other case  Gauthier  found  it  possible,  Avitli  my  direct  cystoscope,  to 
catheterize  a  ureter  the  orifice  of  AA'hich  had  prolapsed  and  taken  the 
shape  of  a  cornucopia.  In  his  OAvn  Avords :  "  It  can  be  said  Avithout  exag- 
geration, that  these  Iavo  patients  OAve  their  liA^es  to  the  direct  vision 
cystoscope." 

3.  Apart  from  these  striking  cases,  it  seems  that  the  direct  Adsion 
cystoscope,  generalh^  speaking,  is  by  far  preferable  in  Avomen,  to  the 
indirect  cystoscope.  The  direct  introduction  of  a  catheter  into  a  female 
ureter  is  the  simplest  and  easiest  matter;  it  takes  but  a  fcAV  seconds. 
Double  catheterization  of  the  ureters  is  also  much  easier  with  the  direct 
than  with  the  indirect  method. 

Quoting  Ferron:  "EA^en  the  manipulation  of  the  catheters  is  sim- 
plified; changing  the  catheters  so  as  to  find  one  that  Avill  enter  the  ure- 
teral orifice,  is  much  more  rapidl3^  accomplished  than  it  can  be  done 
Avith  the  indirect  cystoscope.  Another  real  advantage  is  the  diversity 
of  form  of  the  catheters  that  may  be  used.  With  the  indirect  method 
only  cylindrical  catheters  are  employed.  LaA^age  of  the  pelvis,  for 
instance,  is  greatly  facilitated  by  the  use  of  catheters  having  a  funnel- 
shaped  end.  The  tip  of  the  syringe  adapts  itself  to  the  funnel-shaped 
end  hermetically.  The  quantity  of  fluid  injected  and  consequently  the 
I)elAdc  capacity,  can  be  exactly  determined  Avitli  cylindrical  catheters; 


CATIIK/rKIMZATlOX    Ol"    'I'lIK    I '  iii'/noiis  287 

tliis  osiiiiKitioii  hccoiiics  a  iiiiicii  more  dclicalc  niallcr.  I'jViiafd's  con- 
ical calliclcrs,  llic  distal  calihcr  of  w  liicli  iiH'asiircs  12,  11),  1-4-  Ciiarricfo, 
liavo  f2,ivon  us  oxccllont  service." 

4.  AVitli  (liivcl  vision  cystoscopy,  catlieters  of  relatively  lar^-e  cal- 
ilx'i-  II])  to  No.  IT)  CMiarriere,  can  he  iiisert(Ml  as  far  as  tlie  kidney.  Tlieii- 
larg-e  wide  ruimcl  can  not  ])ass  tliiT)ii,i;'li  tlic  iiai-iow  canal  oi'  llic  indirect 
cystoscoi:)e,  an  advantage  wliicli  Facilitates  co])ious  lavage  hy  ])ei-init- 
ting  tlie  use  of  a  large  syringe. 

5.  In  a  normal  Ijladder  and  under  noi'nial  circumstances,  a  cathe- 
ter manipulated  through  tlie  indirect  cystoscope  may  not  l»e  ahle  to 
enter  the  ureteral  orifice  hecause  it  impinges  on  the  wall  or  slides  over 
it.  Nitze  himself  showed  me  an  instance  of  this  kind  in  Berlin.  In 
these  cases,  on  the  other  hand,  direct  vision  cystoscopy  rarelj^  fails.  In- 
deed, the  catheter,  which  is  kept  rigid  h}^  the  stylet  can  penetrate  the 
ureteral  orifice  much  more  readily  than  with  the  indirect  cystoscope. 

All  that  is  required  is  to  isolate  the  orifice  within  the  lumen  of  the 
cj^stoscopic  tube,  and  perhaps  to  press  the  border  of  the  tube  against 
the  ureteral  orifice;  thus  the  ureteral  meatus  will  protrude  into  the 
tube  and  however  small  it  may  be,  a  catheter  will  usually  penetrate  into 
the  ureter. 

I  employed  this  procedure  on  November  7,  1907,  at  Saint  Louis 
Hospital,  in  the  service  of  Beurnier,  in  a  Avoman  with  symptoms  of 
hydronephrosis,  Avith  a  very  small  ureteral  orifice.  By  the  aid  of  this 
method,  catheterization  was  easil^^  accomplished. 

6.  In  inflamed  and  hemorrhagic  bladders  ureteral  catheterization 
with  the  direct  vision  cystoscope  should  be  preferred.  Jean  Ferron  has 
emphasized  this  jDoint  very  strongly  in  an  interesting  study^  on  ureteral 
catheterization  by  direct  vision  cystoscopy..  He  says: 

"When  the  bla(hler  does  not  tolerate  the  necessary  80  c.c.  of  fluid 
for  indirect  cystoscopy,  some  authors,  hardly  mentioning  Luys'  tube, 
frequently  advise  .surgical  intervention.  That  is,  exclusion  of  the  dis- 
eased kidney,  luml)otomy,  nephrotomy,  ureterostomy.  This  method  of 
procedure  is  suggested  in  some  of  the  most  recent  publications.  Just 
a  few  lines  are  devoted  to  the  suggestion  that  direct  vision  cystoscopy 
is  indicated  when  'cystoscopic  catheterization  is  rendered  impossible 
by  the  unfavorable  condition  of  the  bladder.' 

''Nevertheless  this  method  has  great  advantages.  The  fact  that 
it  has  been  neglected  seems  to  us  unjust  for  more  than  one  reason.  *  *  * 

"In  numerous  instances  of  intolerant  bladder,  with  a  capacity  less 
than  80  c.c.  thus  rendering  cystoscopic  examination  inipossil)le,  Ave  liaA'e 
been  able  to  catheterize  successfully  Avith  Lii>s'  cystoscope.  A  detailed 
description  of  these  cases  need  not  h<?  gi\-en  here:  suffice  it  to  say  they 


^OO  CYSTOSCOPY   AXD    rEETHROSCOPY 

were  observed  by  Poiisson  and  liis  students.    AVe  sliall  relate  the  his- 
tory of  one  very  interesting  case:  *. 

"L.,  aged  thirty-five  years,  postal  clerk,  consulted  me  in  February,  1912,  for  polla- 
kiuria   and  hematuria.     A   brother   and   sister   had   died  of   tuberculosis. 

"In  1902,  while  a  sergeant  major  of  chasseurs,  in  previous  good  health  and  without 
genital  disease,  he  suddenly  developed  a  right  orchiepididymitis,  following  a  trauma.  This 
lesion  increased  gradually,  and  in  1903,  one  year  later,  he  noticed  a  painless  induration  of 
the  left  epididymis.  Discharged  from  ser^-ice,  he  went  home  and  for  a  long  time  did  not 
show  any  sjnnptoms  other  than  the  abnormal  size  of  Ms  epididA-mes.  In  December,  1910, 
after  a  bicycle  ride  he  noticed  his  shirt  was  blood-stained.  In  September,  1911,  his  urine 
was  cloudy,  he  micturated  once  during  the  night  and  the  urine  left  a  deposit  in  the  glass. 
Urinary  frequency  increased.  Separation  of  the  urine  made  by  a  specialist  showed  bloody 
urine  from  the  left  side  and  nothing  whatever  from  the  right  side.  According  to  the 
patient 's  statement  the  right  catheter  was  found  clogged  by  a  blood  clot  when  it  was  with- 
drawn and  examined.  The  physician  made  no  attempt  to  interpret  the  result  of  the  test. 
Tlie  pollakiuria  increased  to  such  an  extent  that  the  urine  was  voided  almost  continuously; 
in  this  condition  he  was  referred  to  us. 

''General  condition  is  fair.  A  superficial  examination  does  not  reveal  anything  but 
two  enormous  epididymes.  The  renal  regions  are  not  painful;  pressure  on  the  hypogastrium 
is  slightly  painful.  Palpation  of  the  ureteral  points  and  Pasteau's  points  is  negative.  The 
urethra  is  free  and  painless ;  the  prostate  is  large  and  uneven ;  urine  very  bloody.  In  spite  of 
a  previous  injection  of  stovaine,  it  is  impossible  to  introduce  into  the  bladder  more  than 
20  to   25   c.c.  of  fluid.     Indirect  cystoscopy  had  to   be   given  up. 

' '  Luys '  tube  passed  easily.  We  found  ourselves  in  the  presence  of  a  rare  form  of 
cystitis.  The  vesical  cavity  is  occupied  by  a  gray,  fringed,  denticulated  false  membrane, 
resembling  felt,  which  covers  the  entire  mucosa.  A  ureteral  ejaculation  indicated  the  site 
of  the  left  ureteral  orifice,  and  a  No.  8  catheter  was  introduced  as  far  as  the  renal  pelvis. 
Analysis  of  the  separate  urines  collected  during  three  and  a  half  hours  (Labat)  is  as  follows: 


Quantity 

Urea  j^er  1,000  c.c. 

Urea    completely    eliminated 

Chloride  of  sodium  per  1,000 

c.c. 
Chloride     of     sodium     com- 
pletely eliminated 
Albumin 
Blood 


LEFT   KIDNEY 

14   C.c. 
12    C.C. 
11.5  c.c. 
7.60-23.60  gm. 
0.706  gm. 

6.40  -  8.40  gm. 

0.220   gm. 
8.-4.  gm. 

All  over  the  field.  Many 
blood  elements,  leucocytes 
predominating.  No  m  i  - 
crobes. 


BLADDER 

(6.5   c.c. 
3    c.c. 
3    c.c. 
22.10-12.60  gm. 
0.219  g-m. 

8.90-7.90   gTQ. 

0.205  gm. 
9.  -  9.  gm. 

All  over  the  field.  Blood 
elements,  leucocytes  predom- 
inating. Few  easts  and 
many  bacilli. 


"Two  days  later,  the  right  ureter  was  catheterized.  The  catheter  was  arrested  at  a 
point  12  centimeters  from  the  orifice  and  only  a  few  drops  of  bloody  urine  were  recovered. 
Another  catheterization  of  the  same  side  gave  the  same  result.  So  then,  all  of  these 
examinations  showed  a  diseased  condition  of  the  right  kidney,  although  the  microscope  did 
not  reveal  any  tubercle  bacilli.  The  results  previously  obtained  by  the  urinary  separation 
were  thus  confirmed.  At  that  tinio,  the  secretion  of  tlie  right  kidney  had  already  become 
considerably   diminished. 


CATHETEltlZATlOX    OF    THE    mETERS  289 

"Nephrectomy  snjigested  itself  at  once.  Before  operating,  liowever,  we  attempted 
to  clear  the  bladder  of  tlic  gray  fringed  pseiidomembranes  which  covered  it.  Tliis  was  ac- 
complished in  several  sittings  by  direct  cystoscopy  using  a  forceps  devised  for  endovesical 
manipulations.  During  this  period  the  patient  for  the  first  time  expelled  a  considerable 
quantity  of  false  membrane  between  the  sittings.  These  membranes  contained  very  dense 
groups  of  Koch  bacilli.  This  fact  was  all  the  more  interesting  because  the  microscopic  ex- 
aminations were  negative  and  guinea  pig  inoculation  of  the  separated  urines  also  proved 
to  be  negative. 

''On  March  22,  1912,  when  the  bladder  had  been  cleared  of  all  the  false  membranes, 
a  lumbar  nephrectomy  was  performed  and  followed  by  a  right  epididymectomy.  The  renal 
j)arenchyma  was  almost  completely  destroyed  and  presented  large  cavities  which  communi- 
cated with  the  pelvis;  the  latter  with  very  thick  walls,  was  continuous  with  a  ureter  whieli 
was  considerably  narrowed  at  certain  points.  The  postoperative  history  was  uneventful. 
The  patient  left  the  hospital  on  the  twenty-seventh  day,  fully  recovered.  He  has  remained 
under  treatment  since  then  for  his  vesical  lesions. 

''In  tliis  case,  distention  of  the  bladder  being  absolutely  impossible, 
LiiYs'  cystoscope  helped  its  to  make  the  diagnosis  of  the  diseased  side 
and  assured  the  integrity  of  the  opposite  organ.  This  was  done  without 
having  recourse  to  comiDlicated  oi3erative  measures  usual  in  such  cases. 
Thanks  to  direct  cystoscoj^y,  we  found  and  treated  a  rare  form  of  tuber- 
culous cystitis,  successfully  catheterized  both  ureters  and  determined 
the  proper  treatment  to  be  adopted. 

"In  conclusion,  we  do  not  pretend  that  Luys'  instrument  and  the 
indirect  cystoscope  are  rivals.  We  do  not  purpose  to  minimize  the 
innumerable  services  rendered  by  the  Albarran  deflector.  We  have 
tried  to  show,  however,  that  in  addition  to  the  classic  method,  uni- 
versally used,  there  exists  a  method  of  catheterization  that  is  not  suffi- 
ciently well  known.  One  of  its  great  advantages  is  a  much  more  thor- 
ough asepsis.  In  an  inflamed  bladder  where  a  kidney  infection  is  to  be 
feared,  the  metallic  tube  (Luys)  is  to  be  preferred  because  it  is  more 
truly  surgical  in  its  simplicity.  Its  employment  is  far  more  practicable 
in  women,  because  of  the  facility  of  manipulation,  and  the  advantage  of 
a  quick  change  of  the  catheters,  when  it  is  desired.  We  do  not  hesitate 
to  repeat  Luys'  assertion  that  direct  vision  cystoscopy  is  the  method 
of  choice  in  the  female. 

"Its  advantages  are  perhaps  not  so  striking  in  the  male.  Never- 
theless we  have  used  it  for  many  months  without  occasion  for  regret. 
A  urethra  with  a  caliber  less  than  normal,  or  an  extremely  obese  patient, 
were  the  only  obstacles  to  this  method  of  examination. 

"Lastly,  we  repeat  that  in  difficult  cases  in  which  the  indirect  cys- 
toscope has  failed,  before  resorting  to  bloody  oiDerations,  direct  vision 
cystoscopy  should  he  attempted,  but  only  l;)y  a  surgeon  who  has  had 
experience  with  Luys'  tube.  In  many  instances  it  will  give  him  im- 
portant information,  without  subjecting  the  patient  to  the  slightest 
risk." 


290  CYSTOSCOPY    AND    URETHROSCOPY 

7.  In  a  bladder  with  trabeculations  or  with  diverticuli,  the  search 
for  the  ureteral  orifice  is  often  extremely  simj)lified  by  the  direct  cys- 
toscope.    Ferron  reports-  the  foUoAving  interesting  case  apropos: 

"In  a  female  patient  in  the  service  of  Pousson,  we  searched  in  vain  for  the  left  ure- 
teral orifice  at  its  normal  site  and  all  around  it;  suddenly,  thrusting  the  extremity  of  the 
tuloe  into  a  very  narrow  diverticulum,  we  saw  the  ureteral  orifice  and  catheterized  it  easily. ' ' 

It  can  be  readily  seen  that  if  the  indirect  cystoscope  had  been  used 
in  this  case,  the  diverticnlnm  in  which  the  ureteral  orifice  was  found, 
would  have  remained  in  the  dark,  undiscovered.  The  superiority  of 
the  direct  vision  cystoscope  is  thus  very  evident. 

8.  A  final  advantage  of  direct  catheterization  is  found  in  the  fact 
that  we  can  better  see  and  demonstrate  to  assistants  tliat  the  catheter 
has  really  entered  the  ureter  and  has  not  merely  slipped  along  the  sur- 
face of  the  mucosa.  Indeed,  by  manipulating  the  tube  properly,  the 
entire  circumference  of  the  catheter  can  be  seen ;  we  can  also  determine 
that  it  is  completely  surrounded  by  mucosa  and  that  it  stands  out  promi- 
nently in  the  bladder,  like  a  flagstaff  dug  into  the  ground. 

Indications  for  Indirect  Cystoscopy  in  Ureteral  Catheterization 

There  are  two  principal  indications  for  the  employment  of  the  in- 
direct c3^stoscope  in  ureteral  catheterization:  1.  In  obese  and  asthmatic 
(congestif)  males.  In  these  patients  the  inclined  position  is  not  easily 
maintained,  and  again,  the  bladder  does  not  distend  itself  well  on  ac- 
count of  the  abdominal  plethora.  In  stout  females  with  marked  gen- 
ital prolapse,  distention  of  the  bladder  in  the  inclined  position  is 
likewise  impossible.  It  is  preferable  to  use  th«  indirect  cystoscope  in 
these  casse.  2.  In  males,  with  the  urethral  meatus  or  the  urethra  itself 
of  a  relatively  small  caliber,  Avhich  does  not  admit  the  tube  of  the  direct 
vision  cystoscope. 

SiTBSEQUEXT    StEPS    IX    UrETEPwAT.    CATHETERIZATION 

As  soon  as  the  catheter  is  properly  placed  and  the  cystoscope 
removed,  a  recipient  (sterile  test  tube)  is  placed  immediately  under- 
neath so  as  to  collect  every  drop  of  fluid;  not  a  single  drop  of  fluid 
should  be  lost,  because  the  ureteral  catheter  may  have  drained  a  renal 
retention  cavity,  the  presence  of  which  and  the  measurement  of  its 
capacity  are  always  important  to  know. 

AVhen  everything  has  progressed  well,  some  time  is  allowed  to 
pass  in  order  to  collect  a  sufficient  quantity  of  urine;  and  when  this 
has  been  done,  the  catheter  may  be  removed.  But  in  the  meantime 
it  is  highly  imiDortant  to  profit  by  the  presence  of  the  catheter  to  deter- 
mine the  pelvic  capacity;  aj)art  from  the  important  information  which 


CATIIKTKIM/A'I'IOX    oi'    '1' 1 1  K    UKETERS  291 

can  lliiis  Itc  ,i;aiii(Ml,  llic  aiilis('|)1i('  soiuiions,  lil<('  llic  l:l()i)0  silver 
iiiii'aic.  Tor  ('xaiii])l(',  have  the  ,i;r('al  N'aliic  ol'  cIcai'iii.L;'  ili<'  pelvis  and 
ui'cici'  of  all  the  |)()ssil)l('  coiilaiiiinalioiis  hi'oii^lit  in  by  llic  lip  of  llic 
callielci'.  If  lliis  is  done,  accidcnls  due  lo  llie  catliolcrization  arc  very 
rarely  seen. 

Tlie  palienl  sliould  lake  certain  precautions  after  catheterization. 
Tnnncdialely  lliercafler,  lie  sliould  i;o  to  hed  for  t\\ enty-four  liours  and 
drink  water  copiously.  He  should  take  two  grains  of  urotroijin  in  twen- 
ty-four hours.  With  these  indispensable  pi'ccaulions,  ureteral  catlieter- 
izalion  can  he  accomplished  without  any  risk  of  injury  to  llic  palienl. 

REFEREISrCES 

iFcrron:      Jour.  cl'Uiol.,   101?.,  iii,  p.  65. 

^Ferron:     A  piopos  du  cntlietcM'isme  ureteral,  Jour.  d'Urol.,  December,   1912,  Obs.  XIX. 

DIFFICULTIES,  ACCIDENTS,  AND  ERRORS  IN  URETERAL 

CATHETERIZATION 

Ureteral  catheterization  can  be  rendered  imjDossible  by  many  cir- 
cumstances, the  principal  being  the  following: 

1.  Difficulties  Inherent  in  Indirect  Cystoscopy. — These  have  al- 
ready been  studied  (see  page  189)  and  will  be  mei'ely  enumerated  at 
this  time,  as  follows :  narrow  meatus,  urethral  stricture,  spasm  of  the 
meml)ranous  urethra,  hypertrophy  of  the  prostate,  cystitis,  very  small 
vesical  capacity,  etc. 

2.  Impossibility  of  Locating  the  Ureteral  Meatus. — Unfortunately 
there  are  numerous  conditions  in  which  the  ureteral  orifice  is  practically 
invisible.  In  pronounced  cystitis,  with  edema  and  inflammation  of  the 
vesical  mucosa,  the  ureteral  orifice  may  be  completely  hidden  among 
the  edematous  masses,  thus  rendering  its  discovery  almost  impossil^le. 
On  the  other  hand,  in  prostatics,  the  orifice  is  displaced,  even  hidden 
behind  the  prostatic  swelling.  In  changes  affecting  surrounding  organs, 
e.g.,  uterine  cancer,  fibroma,  pregnancy,  it  may  be  very  difficult  to  find 
the  ureteral  orifice  and  sometimes  even  impossible  to  see  it  at  all. 

3.  The  Ureteral  Orifice  May  Be  Small. — In  the  same  manner  that 
a  urethral  meatus  is  sometimes  too  small  for  the  introduction  of  a 
sound,  the  ureteral  meatus  is  likewise  occasionally  so  snuill  that  the 
fmest  ureteral  catheter  can  not  be  introduced.  AVhen,  however,  the  lips 
of  the  ureteral  meatus  are  narrowed  congenitally,  and  not  through 
inflammation,  they  can  be  treated  in  the  same  manner  as  the  urethral 
oiifice.  First  Ave  attem])t  to  introduce  a  small  Xo.  5  catheter  with  an 
olivary  tip;  this  is  followed  by  a  No.  6  catheter  which  is  forced  gently 


292  CYSTOSCOPY    AiSTD    URETHROSCOPY 

into  tlie  ureteral  orifice.    In  these  cases,  it  is  always  best  to  use  cathe- 
ters with  an  olivary  tip.  ^ 

4.  Inflammation  of  the  Ureteral  Orifice. — This  is  very  often  due  to 
a  pathologic  change  in  the  corresj)onding  kidney  and  to  a  p^^onephrosis. 
It  may  very  often  prevent  the  introduction  of  a  catheter  because  ulcera- 
tions are  found  around  the  ureteral  orifice  which  bleed  by  the  contact 
with  or  passage  of  the  catheter. 

5.  The  Arrest  of  the  Catheter  a  Few  Centimeters  from  the  Mea- 
tus.— This  obstruction  is  relatively  frequent  and  takes  place  about  two 
to  four  centimeters  from  the  meatus.  There  are  various  causes.  In  the 
first  place  the  ureter  is  narrowest  at  this  point;  secondl}^,  the  ureter 
bends  across  the  bifurcation  of  the  pelvic  blood  vessels  at  this  point  at 
the  level  of  the  promontory. 

In  the  presence  of  these  difficulties,  certain  expedients  must  be  re- 
sorted to ;  one  of  the  most  useful  is  to  vary  the  flexion  of  the  thighs  over 
the  pelvis,  thus  increasing  or  diminishing  the  amount  of  flexion.  In 
this  way,  the  introduction  of  the  ureteral  catheter  can  be  facilitated. 

6.  The  Ureteral  Catheter  Does  not  Drain. — Unfortunately,  this  is 
not  a  rare  occurrence  and  may  be  due  to  several  causes;  one  of  the  prin- 
cipal causes  being  that  the  extremity  of  the  catheter  is  in  a  faulty  posi- 
tion, having  been  introduced  too  far  into  the  renal  pelvis.  In  such 
circumstances  it  is  advisable  to  withdraw  the  catheter  slowly  for 
about  two  or  three  centimeters,  and  the  flow  will  be  reestablished. 

Occasionally  in  spite  of  this  procedure,  the  catheter  still  does  not 
drain.  We  must  then  exercise  patience  and  wait  ten  or  fifteen  minutes. 
At  the  end  of  that  time  droplets  of  pus  or  tiu}^  blood  clots  are  seen 
emerging  from  the  catheter,  thus  exj)laining  the  cause  of  the  previous 
failure  of  drainage. 

In  still  other  cases,  in  spite  of  all  one's  patience,  the  urine  persists 
in  refusing  to  flow.  An  attempt  should  be  made  to  clear  the  catheter 
of  possible  obstructions,  by  injecting  a  small  quantity  of  fluid  into  its 
interior.  This  expedient  should  be  utilized  only  as  a  last  resort,  because 
the  chemical  analysis  of  the  urine  w^ill  be  changed  as  a  result  of  the 
fluid  injected.  The  urinary  secretion  is  thus  diluted  with  a  quantity  of 
water  which  it  is  very  difficult  to  estimate  properly. 

7.  The  Catheter  Drains  Too  Much. — This  is  not  properly  speaking 
a  serious  disadvantage,  but  it  is  well  to  know  how  to  interpret  this 
polyuria  projDerly.  It  may  be  due  simply  to  the  evacuation  of  a  hydro- 
nephrosis; the  exact  quantity  of  the  flow  should  be  measured  and  re- 
corded. 

It  may  also  be  due  to  the  renal  irritation  produced  by  the  intro- 
duction of  the  catheter.    A  very  simple  method  of  differentiating  these 


CATIIKTKKI/A'IIOX     oi      'llll':     t    IIK'IKIIS  293 

coiidilioiis  ;iii<l  lliii.-  iii;iUiii,t;'  a  correct  dia.^iiosis,  is  lo  study  tlic  cliar- 
acter  of  the  llow;  wlicii  tlic  ovacualioii  lakes  the  roim  of  a  jet,  or  is  a 
coiitiimoiis  llow  without  iiilurinis.sion,  it  is  inoi'e  than  ])i'ol)ahh'  that  nv<' 
ai'i'  (h-aliiii;'  \\\\\\  the  evacuation  of  a  liydi-ouejjhiosis.  When,  to  tlie 
conti'ai'y,  tlie  ureteral  ejaculations  arc  decidedly  i-liythuiic,  with  inter- 
vals duriii,*;-  ^\■hicll  urine  does  not  llow,  a  ph_\siologic  excitation  of  tlie 
kidney  nuist  l)e  the  canse. 

8.  The  Flow  Is  Blood  Stained. — This  is  also  a  i-elatively  fieciuent 
occurrence  in  catlieterization.  It  may  be  said  to  be  constant,  because 
microscopic  examination  of  catlieterizecl  nrine  invariably  reveals  some 
blood  cells.  Their  presence  is  easily  explained;  the  catheter  in  passing- 
through  the  nreteral  interior  necessarily  injures  the  ureteral  mucosa 
to  some  degree  and  thus  usually  produces  a  slight  hemorrhage.  This 
may  be  negligible  or  simply  microscopic;  on  the  other  hand,  it  may 
be  nuicli  more  important  especially  when  the  kidneys  do  not  function- 
ate steadily  and  when  the  renal  pelvis  is  not  properly  cleansed  by  a  suf- 
ficient quantity  of  urine. 

Accidents  Associated  With  Ureteral  Catheterization 

The  accidents  which  may  occur  in  connection  with  ureteial  cathe- 
terization are  either  mechanical  or  infectious  in  character. 

Mechanical  accidents  are  relatively  very  rare.  Perforation  of  the 
ureter  has  been  reported,  but  this  is  an  extremely  unusual  occurrence. 
Infectious  accidents  are  more  serious  and  more  fre((uent. 

Infection  of  a  Healthy  Kidney  by  the  Ureteral  Catheter. — A  ure- 
teral catheter  introduced  through  the  indirect  cystoscope  in  an  infected 
liladder  filled  with  fluid  may  carry  joathogenic  germs  into  the  renal 
pelvis  and  thus  bring  about  an  infection  in  a  previously  healthy  kidney. 

This  is  an  undeniable  and  undoul)ted  fact,  and  it  has  been  observed 
by  numerous  authors.  This  accident  may  result  in  spite  of  copious  and 
repeated  irrigation  of  the  bladder.  It  is  a  fact  well  known  to  all  who 
practice  indirect  cystoscopy,  that  even  after  the  bladder  has  been  thor- 
oughly ii-rigated  and  the  lluid  comes  out  perfecth'  clear,  the  vesical 
nmcosa  is  not  absolutely  clean.  This  is  mad(^  evident  by  the  numer- 
ous impurities  that  can  be  seen  floating  in  the  fluid  through  th(^  lenses 
of  the  cystoscope.  The  catheter  coming  in  contact  with  this  lluid,  be- 
comes infected  not  only  on  its  external  surface,  but  likewise  in  its 
interior,  which  is  far  more  seiious.  In  this  wav  the  catheter,  soiled 
with  inii)urities  "intns  et  extra,"  becomes  a  ^xM'fect  carrier  of  microbic 
elements  which  can  and  ina\'  infect  the  pelvis  and  the  hidney. 

This  is  fully  confirmed  in  a  report  of  a  typical  case  by  Rafin, 
of  Lyons,^  who  found  that  spcrniafnznirls  icere  evacuated  iliroiir/h  a 


294  CYSTOSCOPY    AND    URETHROSCOPY 

catheter  inserted  in  a  ureter!  ''In  a  patient  who  had  to  be  anesthetized 
because  of  the  limited  capacity  of  the  bladder,  I  found  spermatozoids 
in  the  urine  evacuated  through  the  ureteral  catheter,  although  a  thor- 
ough washing  of  the  bladder  was  previously  effected.  It  is  probable 
that  the  patient  emptied  his  seminal  vesicles  during  the  struggle  in  the 
early  stage  of  the  anesthesia ;  the  sperma  Av^ere  carried  into  the  bladder 
by  the  cystoscope  and  the  vesical  fluid  containing  a  considerable  quan- 
tity of  spermatozoids  in  suspension,  had  thus  filled  the  ureteral  cathe- 
ter with  them." 

But  this  is  not  all:  Apart  from  the  fact  that  the  ureteral  catheter 
may  become  a  carrier  of  microbian  elements  capable  of  infecting  the 
pelvis  and  kidney,  in  a  direct  manner,  as  just  mentioned,  infection  of 
the  kidney  may  take  place  indirectly  as  well.  When  the  catheter  passes 
into  the  ureter,  it  forces  the  ureteral  valve, — the  "guardian  of  the  ure- 
ter;" an  ascending  infection  may  be  produced  as  a  result  of  this  forcing 
of  the  ureteral  valve. 

In  these  circumstances,  there  is  a  reflux  of  the  infected  vesical  fluid 
into  the  ureter.  Margulies-  has  stated:  ''We  have  occasionally  noticed 
the  reflux  of  the  boric  solution  from  the  bladder  into  the  ureter,  and  its 
subsequent  elimination  through  the  ureteral  catheter.  Casper  was  the 
first  to  call  attention  to  this  fact;  for  proof,  he  injected  coloring  sub- 
stances into  the  bladder  and  immediately  afterward  these  substances 
were  eliminated  through  the  ureter. 

[The  editor  observed  a  case  but  recently  which  gave  the  follow- 
ing confirmatory  phenomena:  The  patient  was  taking  methylene,  blue 
internally  and  the  urine  was  colored  deep  green.  A  kidney  lesion  was 
suspected  and  the  bladder  Avas  filled  with  oxycyanid  solution  prepara- 
tory to  cystoscopy  (indirect)  and  catheterization  of  the  ureters.  When 
the  catheters  were  inserted,  it  was  found  that  the  left  catheter  was 
draining  green  urine,  and  the  right  was  draining  white  fluid,  probably 
the  oxycyanide  solution.  With  both  catheters  in  situ,  draining  color- 
less and  green  fluid,  respectively,  a  solution  of  permanganate  of  potas- 
sium was  injected  into  the  bladder  through  a  vesical  catheter,  and  im- 
mediately the  white  fluid  emerging  from  the  right  ureter  was  changed 
to  red,  whereas  the  green  urine  continued  to  come  through  the  left 
catheter  as  before.  This  proved  undeniably  that  the  left  catheter  was 
draining  the  left  kidney  urine,  but  that  the  fluid  which  came  from  the 
right  catheter,  was  merely  the  bladder  fluid  which  was  being  "sucked 
up,"  so  to  speak  into  the  ureter  by  the  "reflux,"  and  was  passing  out 
through  the  catheter.  On  operation  it  was  later  found  that  the  right 
kidney  was  atrophied  and  was  not  functioning  at  all. — Editor.] 

Deschamps  also  said  in  his  monograph;^  "The  experiments  of 
Lewin  and  Goldschmidt,  of  Courtade  and  F.  Guyon,  have  demonstrated 


(•A'riii'yi'i';i;i/,A'ri().\   oi'  tii 


n;KTKi:s  295 


tlial  a  red  UN  of  1  he  hiaddci'  urine  low  ai-<l  I  lie  iirdci-  can  he  pi-oducc*!,  l)ul 
only  ai  cciiaiii  iiioiiiciils;  i.e.,  when  I  lie  \al\  ulc  opens  to  I'elease  tlie  iirc- 
loral  (low.  In  llie  normal  state,  lliis  icllux,  in  oui-  opinion,  is  a  Tiog]i,i;-il)l(' 
cause  of  aseendin.i;'  infoetion;  l)ut  when  a  iii-eler  has  heon  oatlioterized, 
and  llie  valvule  has  been  foi'ccd  o]xmi,  it  is  possi])l('  tliat  tlic  Tcflux  takes 
place  much  more  easily,  the  harrier  does  not  seal  tlie  opening-  hermetic- 
ally and  the  bladder  can  push  its  infecting-  fterms  toward  the  ureter." 
Israel,"  in  a  critical  analysis  of*  ureteral  catheterization,  insists  upon 
the  dang-er  of  ascending-  infection.  He  reports  the  case  of  a  physician 
suffering'  from  an  old  ui-ethritis,  Avith  a  sli<;-lit  cystitis;  Casper  catheter- 
ized  one  of  his  ureters  because  of  a  jDain  in  tlie  luml)ai-  ref^ion.  The 
urine  thus  collected  by  the  catheter  was  clear  and  tlie  patient  was  glad 
to  know  that  his  kidney  w^as  in  normal  condition.  But  on  the  evening 
of  the  same  day  he  was  suddenly  seized  with  vomiting,  fever,  lumbar 
])aiiis,  and  chills,  and  he  voided  purulent  urine.  This  unfortunate  con- 
dition lasted  a  long  time  and  the  patient  finally  died.  Tlie  following  is 
a  complete  history  of  the  case,  as  connuunicated  to  me  by  Israel,  Octo- 
ber 10,  1908: 

Dr.  G.,  physician  at  Rostow-on-Don,  Russia;  had  gonorrhea  at  the  age  of  twenty-four 
(1893).  Urine  became  slightly  cloudy.  Irrigation  of  the  bladder  unsuccessful.  In  1897 
right  ureteral  catheterization  by  Casper:  Right  kidney  urine  perfectly  clear,  no  albumin, 
normal.  The  following  evening  chills,  vomiting,  fever,  which  lasted  two  or  three  weeks. 
Urine  became  cloudy  immediately  after  catheterization.  During  the  two  years  following, 
there  were  occasional  attacks  of  chills,  vomiting,  and  fever,  lasting  one  or  two  days;  pain  in 
right   kidney   region   for   several   months    past;    cloudy   polyuria. 

From  that  time  on,  the  patient  always  suffered  pain,  the  febrile  attacks  recurring  at 
irregular  intervals.  He  became  gradually  pale  and  weaker.  On  February  6,  1906,  he  came 
to  my  clinic,  pale  and  weak,  without  appetite,  tongue  dry,  continuous  headache,  and  cloudy 
polyuria.     Nine  days  later,  he  died  in  uremic  coma. 

At  the  same  time  Israel  sent  me  the  histories  of  two  additional 
cases  in  which  renal  infection  resulted  from  ureteral  catheterization. 
The  following  are  these  histories  as  written  by  the  author  himself: 

Case  1. — Mile.  Melanie  C,  aged  thirty-four  years.  Right  intermittent  hydronephro- 
sis; nephroptosis.  Normal  urine.  From  time  to  time,  attacks  of  colic  lasting  two  or  three 
hours.  After  and  between  these  attacks  she  felt  perfectly  Avell.  On  July  16,  1900,  right 
ureteral  catheterization;  the  instrument  is  arrested  just  above  the  vesical  orifice  of  the  ureter. 
July  21,  ureteral  catheterization  is  repeated  with  the  same  result;  July  22,  patient  quit  the 
liospital.  She  came  back  on  August  10  to  be  operated  upon.  Since  she  left  the  hospital, 
she  complains  of  nausea,  vomiting,  and  frequent  palpation  of  the  heart.  Urination,  pre- 
viously normal,  is  now  increased  in  frequency  to  twelve  tiincs  in  twenty-four  hours;  pain 
in  the  bladder  and  urethra  after  micturition.  Tlio  riglit  kidney  more  enlarged  than  in 
July,  and  is  the  seat  of  continuous  pain;  colic  from  time  to  time.  Palpation  of  the  right 
kidney  is  painful. 

The  urine  is  cloudy  and  contains  many  leucocytes,  a  few  erythrocytes  and  nuuiy  hy- 
alin  and  granular  easts.  Evening  ten\|u'rnlinr   .".IM"   C.     Vomiting;    oliguria. 

August   20,   right   nephrectomy.      A    huge   cavity   filled   with   pus;    an   abscess   the   size 


296 


CYSTOSCOPY    AND    UEETHKOSCOPY 


of  a  waluut  and  several  small  ones  in  the  cortical  substance.  The  mucosa  of  the  pelvis  and 
calices  is  red,  ecchymotic,  thickened. 

Case  2. — Bessie  C,  aged  twelve  years,  of  London.  Grandfather  and  two  *fencles.  died 
of  tuberculosis.  For  the  last  five  years,  weak,  without  appetite;  poUakiuria,  enuresis.  Five 
months  later  Koch  bacillus  found  in  the  urine.  She  improved  slowly.  Three  years  ago,  she 
complained  of  slight  pains  in  the  right  kidney.  At  present  she  feels  well,  urination  every 
two  and  a  half  or  three  hours.  No  pain  on  urination,  no  pain  in  the  kidney.  Temperature 
normal;  she  never  had  fever.  Urine  pale,  hazy;  specific  gravity,  1,004;  albumin  0.25  per 
1,000  CO.     Many  leucocytes;   two   or  three  hyaliu  casts;   numerous  Koch  bacilli. 

June  27,  cystoscopy  under  anesthesia:  Mucosa  inflamed,  covered  with  fibrinopurulent 
membranes;  the  process  is  more  marked  on  the  right  side  than  on  the  left;  catheterization 
of  the  left  ureter;   catheter  in  the  bladder.     Urinalysis: 


FaOHT  KIDNEY 


LEFT  KIDNEY  (BLADDER) 


Urine  pale,  clou( 

3y 

Urine  pale,   cloudy 

Specific   gravity 

1,009    . 

Albumin    0.33   per   1,000 

c.c. 

1.65  per  1,000  c.c. 

Many  leucocytes 

Many  leucocytes 

Urea  1.4  per   1,000   c.c. 

3.6  per  1,000  c.c. 

Freezing   point 

-0.60° 

-0.52° 

Few  Koch  bacilli 

TEMPERATURE 

Many  Koch  bacilli 

Date 

Morning 

Evening 

June 

28, 

38.6°  C. 

i  I 

29, 

38.°  C. 

40.3 

e  e 

30, 

37.6 

38.8 

July 

1, 

39.5 

39.2 

i  i 

2, 

39.6 

39.8 

C  i 

3, 

38.2 

39.1 

i  c 

4, 

37.8 

37.9 

i  i 

5, 

37.4 

37.5 

i  I 

6, 

36.8 

37.4 

i  i 

7, 

37.8 

38.8 

i  i 

8, 

39.2 

39.2 

i  i 

9, 

38.4 

38.2 

June  28,  nausea,  very  frequent  vomiting. 

"  29,  pain  in  both  kidneys 

"  30,  urine  very  purulent 

July  1,  tenesmus  every  ten  minutes 

"  2,  tenesmus  day   and  night,  very   painful 

^'  3,  vomiting 

' '  4,  much  vomiting ;   oliguria 

"  5,  extreme   nervous   agitation,  legs   and   hands   cold 

"  6,  vomiting  of   black  masses 

"  7,  vomiting    of   black  masses 

^'  8,  quantity    of    urine    increased 

' '  9,  convulsions  in  left  arm 
Coma. 

This  autlior  also  reports  a  case  of  renal  abscess  wliicli  lie  attributes 
to  ureteral  catlieterization  performed  a  few  weeks  previous  to  a 
nephrectomy  done  for  a  neoplastic  kidney  (DeschamiDs). 


CATMETEKI/ATIOX     ol       llll':     I '  KI'/l'KltS  297 

I  laii  iiiaiiii  also  says:'  "I  liavc  sccmi  a  ])ali('ii1  wlio  incx'iitcil  syiiip- 
loiiis  ol'  |-i,i;li(  |»y('loii('|)lirilis  I'oi'  a  loii.i;-  lime,  and  who  sliowcci  syiii|i1oiii> 
of  left  pyelonephritis  Tor  the  first  thue  a  few  weeks  after  a  iircitcial 
cathetorizatioii  perf'oriued  l)y  one  of  my  colleagues.  These  iiifcrlions 
are  perhaps  more  frequent  than  it  is  tliou^lit,  Ix'cause  they  inaiiilest 
themselves  only  a  certain  time  after  the  catheterization." 

At  Johns  Jl()])kins  Hospital,  Sam])son''  had  a  fatality  icsultiii;;-  from 
an  ascending-  ureteral  infection;  this  was  caused  by  a  catiictci-  h-fl  /// 
i>itii  as  a  guide  during  hysterectomy  for  a  cancer  of  the  uterus. 

Tlie  dangers  of  a  catheter  left  m  situ  may  he  seen  in  the  i'ol lowing 
history  of  a  characteristic  case  reported  l^y  Legueuf  "This  (tli<'  ure- 
teral catheter  a  demeure)  carries  the  risk  of  causing  almost  certain  in- 
fection of  the  cavity.  I  employed  it  in  a  patient  with  an  enormous  left 
hydronephrosis;  catheterization  was  easy,  although  the  operation, 
which  was  performed  later,  showed  a  pronounced  stricture ;  and  I  evacu- 
ated nearly  three  and  one-third  liters  of  urine  through  the  catheter. 

"Having  repeated  this  evacuation  several  times,  I  wanted  to  intro- 
duce a  catheter  a  demeure  to  permit  the  cavity  to  contract.  But  within 
three  days,  the  urine  became  cloudy,  the  temperature  rose,  and  I  was 
comjoelled  to  abandon  catheterization  and  perform  ureteropyelotomy 
as  quickly  as  possible.  The  operation  Avas  done  transperitoneally.  Tlie 
infection  of  the  cavity  spread  to  the  opened  serous  membrane  and  the 
patient  died  of  peritonitis  in  a  few  days. ' ' 

Tuffier*  expresses  the  same  opinion:  "I  was  consulted  by  a  woman 
fi'om  Geneva.  She  had  been  treated  for  a  long  time  in  Paris,  for  a 
douljle  pyelitis.  According  to  her  statement,  ureteral  catheterization 
performed  for  diagnostic  purposes  had  greatly  aggravated  her  condi- 
tion. I  know  of  another  patient,  from  the  environs  of  Lille,  who  died 
lifteen  days  after  a  diagnostic  ureteral  catheterization." 

Desnos  likewise  had  to  remove  a  kidney  infected  with  tubercle 
bacilli,  carried  by  the  ureteral  catheter,  when  passed  through  the  pros- 
tatic region  in  the  course  of  a  suppurative  prostatitis. 

Concerning  this  grave  danger  of  infection,  the  answer  has  been 
made,  that  ureteral  catheterization  should  be  performed  oidy  on  a 
kidney  supposed  to  be  diseased  and  already  infected;  in  the  iiicaiitinu' 
the  urine  excreted  by  the  opposite  kidney  dii-ectly  through  the  ureter 
is  collected  by  a  catheter  in  the  bladder.  But  tlie  clinical  lindings  (we 
have  ample  proof  in  several  cases)  are  sometimes  absolutely  Avrong, 
;and  ureteral  cathetci-ization  of  a  healthy  kidney  might  l>e  performed 
on  their  data  alone,  thus  submitting  the  ])atieiit  to  the  risk  of  an  infec- 
tion, as  we  have  shown.    In  point  ot  fad,  ureteral  catheterization  with 


298  CYSTOSCOPY   AXD    URETHROSCOPY 

the  direct  \T.sion  cystoscope  seems  to  be  the  most  desiraliU/  method  of 
preventing  the  infection  of  a  healtliy  kithiey  via  the  ureteral^eatheter. 

EEFEEEXCES 

iRafin:      Separation  endovesicale .  et  eatheterisnie  ureteral,  Lron  med.,  Feb.   12,   1905. 

-Margtdies,  cited  by  Kejdel:  Beitrage  zur  funktionellen  Nierendiagnostik,  Gentralbl.  f. 
d.  Eaankh.  d.  Harn-u.  Sex.-Org.,  May  25,  1905,  xvi,  ISTo.  5,  p.  225. ' 

sDeschamps:      Diagnostic  des  affections  chii-urgieales   du  rein.  Paris.   Steinlieil,  1902. 

^Israel:  Was  leistet  der  Ureterkatheterismus  in  der  NierencMi-ui-gie f  Berl.  klin.  Wdmschr., 
January,  1S99,  No.  2. 

sHartmanu:     Thesis  Fontanilles,  Lyons,  1901,  p.  56. 

GReported  by  Vale:     Ann.  Surg.,  January,  1905,  No.  115,  p.  96. 

'Legueu:  A  propos  des  operations  consei-vatrices  dans  les  retentions  renales,  Tr.  13th.  Inter- 
national Congiess  of  Medicine  of  Paris,  1900,  Section  of  Urinary  Surgery,  August  3, 
1900,  p.  15. 

sTuffier:     Bull,  et  mem.  Soc.  de  chir.  de  Paris.  1900.  p.  585. 

Errors  Associated  With  Ureteral  Catheterization 

Inacciiracy  is  an  important  factor  in  the  errors  associated  Avith 
ureteral  catheterization.    There  are  five  principal  sources  of  error : 

1.  It  is  impossible  to  be  certain  tliat  the  caliber  of  the  ureteral 
catheter  will  adapt  itself  tightly  to  that  of  the  ureter.  Consequently 
some  urine  might  dribble  down  between  the  walls  of  the  catheter  and 
the  ureteral  wall,  and  thus  get  mixed  with  the  urine  of  the  opposite  kid- 
ney which  flows  directly  into  the  bladder,  and  thereby  falsify  the  re- 
sults. '      '^ -^ 

This  flow  of  a  certain  cpiantity  of  urine  between  the  catheter  and 
the  ureteral  wall,  is  indeed  undeniable,  and  I  have  oV) served  it  fre- 
quently during  lavage  of  the  pelvis  carried  out  for  therapeutic  pur- 
poses. In  point  of  fact,  the  silver  nitrate  used  for  irrigation  of  the  pel- 
vis very  often  drained  into  the  bladder,  where  it  could  easily  be  detected 
on  collecting  the  vesical  contents  with  a  catheter  at  the  termination  of 
the  lavage.  This  vesical  fluid  usually  showed  an  aliundant  precipitate 
of  characteristic  silver  chloride;  this  clearly  proved  that  the  silver 
nitrate  solution  which  had  been  used  for  lavage  of  tlie  kidney  had 
trickled  into  the  bladder  between  the  catheter  and  the  ureteral  wall. 

The  Ijest  proof  of  the  fact  that  the  urine  often  drains  (ioAvn  Ijetween 
the  catheter  and  tln^  urettual  Avail,  is  obtained  by  catheterization  of 
both  ureters  and  leaving  the  catheters  a  demeure  for  some  time.  Clear 
urine  may  issue  out  of  each  kidney  through  its  respective  catheter:  at 
the  same  time,  a  certain  quantity  of  urine  is  often  found  in  the  bladder. 
which  can  be  withdraAvn  liy  the  introduction  of  a  Xelaton  catheter  into 
the  bladder.  This  affords  certain  proof  of  the  leakage  of  urine  betAveen 
one  of  the  two  catheters  and  its  ureteral  Avail. 


CATHETERI/ATIOX    OF    THE    URETERS  299 

This  soincc  of  i-iror  in  inctcial  callioterization  lias  also  been  re- 
corded by  Kouziictzky,  of  Pctro;;ra(l.'  In  ordci-  to  prevent  this  occur- 
rence, he  cathoterizcs  hotli  ureters  and  then  empties  the  bladder;  after 
the  examination,  before  removing-  tlie  ureteral  catheters,  he  again 
empties  the  bladder  of  its  contents.  Tliis  will  establish  the  quantity  of 
the  urinary  leakage  into  the  bladder.  In  only  twelve  out  of  twenty-two 
cases  was  he  able  to  prevent  its  occurrence.  In  one  case,  a  woman,  in 
spite  of  three  distinct  attempts  and  the  use  of  a  Xo.  8  catheter,  he  was 
unable  to  prevent  tliis  leakage.  In  two  cases,  the  urinary  leakage 
amounted  to  194  and  148  c.c.  respectively,  for  a  period  of  two  hours. 

A  very  characteristic  case  apropos  of  this  subject  was  referred  to 
me  in  the  service  of  Rochard,  at  Saint  Louis  Hospital,  on  October  14, 
1907.  It  was  the  case  of  a  young  woman  with  a  very  large  and  adher- 
ent tumor  in  the  right  hypochondrium ;  she  also  had  pyuria.  By  request, 
I  catheterized  both  ureters  with  the  direct  cj'stoscope,  with  the  follow- 
ing result:  On  the  left  side,  abundant  urine,  but  distinctly  bloody;  on 
the  right  side,  not  a  drop  of  fluid.  After  waiting  half  an  hour,  a  cathe- 
ter was  introduced  into  the  bladder,  Avhich  gave  forth  about  twenty 
c.c.  of  cloudy,  bloody  urine.  Both  ureteral  catheters  were  positively 
in  the  ureters,  because  their  presence  Avas  verified  by  all  the  assistants 
present.  We  were  undoubtedly  dealing  witli  a  distinct  leakage  between 
the  catheter  and  the  ureter. 

In  another  case,  equally  clear,  I  obserA'ed  the  trickling  of  urine 
between  catheter  and  ureter.  A  woman,  Mme.  L.  J.,  aged  37  years, 
entered  the  service  of  Demoulin,  at  the  Saint  Louis  Hospital,  on  Octo- 
ber 2,  1907.  In  the  right  hypochondrium  she  presented  a  large  mass  in 
which  distinct  fluctuation  could  be  felt;  the  urine  was  purulent.  By 
request,  I  examined  lier  under  chloroform,  on  XoA^ember  12,  with  my 
direct  cystoscope.  Although  the  capacity  of  the  bladder  was  only  about 
40  c.c,  I  found  the  following:  On  the  right  side,  an  enlarged  ureter, 
which  emitted  abundant  purulent  ejaculations  Avith  Avhite,  thick  creamy 
pus.  I  catheterized  this  ureter  with  a  Xo.  7  catheter,  Avhicli  penetrated 
easily  about  10  cm.,  but  Avas  arrested  at  that  point. 

This  catheter  Avas  AvithdraAvn,  and  the  left  ureteral  orifice  inspected. 
At  first,  it  Avas  hidden  by  false  membranes,  but  it  Avas  soon  discoA'ered. 
The  bladder  Avas  cleaned  and  dried  Avith  small  SAvabs,  and  a  Xo.  6 
catheter  easily  introduced  into  the  left  ureter  and  left  there  for  three 
quarters  of  an  hour.  During  this  time  a  Xelaton  catheter  Avas  left  in 
the  bladder  to  collect  the  urine  from  the  right  kidney.  At  the  end 
of  the  period,  the  separate  urines  from  the  ureteral  catheter  and  the 
Idadder  catheter  amounted  to  practically  the  same  quantity.  Analysis 
nuide  by  the  pharmacist  of  the  service  showed:   Left  kidney  (through 


PLATE  XIX 

Fig.  1. — Cancerous  tumors  of  the  bladder.  In  this  case,  the  entire  vesical 
wall  was  invaded  by  a  neoi^lastic  deposit,  similar  to  that  represented  on 
the  vesical  floor. 


PLATE  XIX 


CATIIKTKIIIZATIOX    OF    Tl  I  F    URETERS  301 

iM-('l(M-;il  callictt'i')  :  ri'cn,  li>  ,t;i';mis  |)ci-  lilcr,  and  cliloi'idcs,  4.!)()  ,ui-aiiis 
per  litci-.  Iii,i;li1  kidiic)  (1  Im()1i,i;Ii  Vf'sical  catliclci-) :  IJroa,  1-!  ,i;raiii<  pci' 
liter,  and  chloi-idcs,  i)Sh)  grains  per  liter. 

On  Novoiiilx'i-  15,  Avitli  tlic  assistance  of  Dciiioiiliii,  I  ti('])lii-o('t()- 
mized  tlie  riftld  kidney;  I  fonnd  it  reduced  to  a  (lal»l)y  slidl  in  ^vl^K•1l 
not  a  trace  of  parenchyma  could  l)e  detected.  Undoubtedly,  tlie  result 
furnished  by  the  vesical  catheter  -while  the  left  ureter  Avas  bein^?  cathe- 
terized,  was  erroneous.  The  urine  of  the  left  kidney  liad  drained  be- 
tween tlio  ureter  and  the  catheter  and  had  trickled  into  the  bladder. 
Both  urines  in  spite  of  the  difference  in  tlieir  chemical  composition,  ha<l 
i-eally  been  derived  from  the  left  kidney  alone. 

During*  the  operation,  I  was  also  easily  enabled  to  determine  the 
cause  of  the  ureteral  obliteration.  This  was  due  to  a  kink  of  the  ureter 
in  the  shajie  of  an  S,  the  result  of  a  periureteritis.  A  catheter  intro- 
duced through  the  renal  end  of  the  ureter  was  distinctly  arrested  and 
could  not  be  advanced. 

Cathelin-  reported  an  unfortunate  error  Avhich  resulted  from  ure- 
teral catheterization,  and  which  culminated  in  tlie  death  of  the  patient. 
A  man,  aged  fifty-seven  years,  complained  only  of  pain  in  the  right 
kidney;  he  never  had  any  pus,  blood,  or  gravel  in  the  urine. 

Cystoscopy  and  ureteral  catheterization  gave  these  results: 

right  kidney  left  kidxey 

(catheterized)  (bladder  LTRIXE) 

Quantity                                                      15  c.c.  10  c.c. 

Urea    (per   liter)                                       13.45     gm.  13.24  gm. 

Chlorides    (per  liter)                                10.50     "  9.50     " 

Deposit                                         Numerous   broken   down  Xumerous  blood  cells, 

blood  cells.  few  renal   cells. 

"Relying,"  says  Cathelin,  "on  the  excellence  of  the  urine  recov- 
ered through  the  vesical  catheter,  and  fearing  that  the  patient  would 
not  derive  any  benefit  from  a  simple  exploratory  operation,  we  decided 
upon  a  nephrectomy. 

"Subsequent  History:  The  first  day,  150  c.c.  of  urine  were  recov- 
ered from  the  bladder;  the  second  day,  50  c.c;  after  that,  nothing,  in 
spite  of  the  administration  of  lactose  and  theobromine.  The  fourth  day, 
in  view  of  this  persistent  anuria,  we  decided  to  do  a  nephrostomy  of 
the  left  kidney.  This  operation  showed  the  total  absence  of  the  kidney 
on  that  side.  The  patient  died  on  the  seventh  day,  and  the  autopsy 
confirmed  the  operation  liiidings.  There  was  neillier  kidney  nor  ureter 
on  the  left  side." 

Nicolich  has  reported  a  case  in  which  an  error  was  made  as  n  re- 
sult of  ureteral  catheterization  and  confirmed  by  autopsy-  "A  woman, 


302 


CYSTOSCOPY   AND    URETHEOSCOPY 


complained  for  a  long  time  of  purulent  urine,  and  frequent  and  painful 
urination.  The  right  kidney  was  palpable  and  a  little  painfiJ;  the  left 
kidney  was  not  palpable.  Downes'  instrument  was  used  and  left  in 
place  for  half  an  hour;  the  right  tul)e  then  gave  purulent  urine,  while 
not  a  drop  of  urine  could  be  obtained  from  the  opposite  side.  Catheter- 
ization of  the  right  ureter  showed  a  retention  of  pus  in  the  right  kid- 
ney; the  catheter  was  left  in  situ  for  twelve  hours,  Avith 
this  result:     Urine  from  the  catheter,  quantity,  400  c.c. 


u.  w. 


cloudy,  purulent;  urine  from  the  bladder,  quantity,  180 
c.c,  cloudy,  purulent,  bloody.     This  result  might  have 
been  interpreted  to  mean  that  the  left  kidne^^  although 
Ij,   „^  more  diseased  than  the  right,  was  actually  functionating, 

^  H  although  as  a  matter  of  fact,  it  did  not  functionate  at  all, 

because  it  was  found  to  be  completely  atrophied." 

These  observations  indicate  what  might  happen 
when  the  caliber  of  the  ureteral  catheter  is  smaller  than 
that  of  the  ureter  itself.  When  catheterization  of  both 
ureters  is  performed  Avith  the  indirect  cysto scope,  only 
small  catheters  can  be  used,  and  if  catheterization  is 
continued  for  several  hours,  the  urine  will  continually 
trickle  down  between  the  catheter  and  the  ureteral  wall, 
so  that  it  will  be  impossible  to  estimate  exactly  the  quan- 
tity of  urine  furnished  by  each  kidney.  On  the  other 
hand,  if  a  larger  catheter  is  used,  and  the  ureter  is  too 
narrow  to  accept  it,  the  ureter  will  bleed. 

The  answer  to  this  criticism  Avas  given  at  the  Mad- 
rid Congress.-'     Nitze  at  that  gathering,  presented  new 
ureteral    catheters    provided    with    double    canalization 
(Fig.  193),  one  for  the  floAV  of  urine,  and  the  other  for 
the  injection  of  water  into  a  small  rubber  bulb,  Avhich 
when  filled  with  water,  comes  into  firm  contact  Avith  the 
ureteral  Avails.    But  this  modification  acts  as  a  detriment 
to  the  interior  caliber  of  the  catheter,  for  the  latter  thus 
becomes   too   narroAV  for  the   free   passage   of   slightly 
thickened  pus  or  small  blood  clots. 
Various  methods  have  been  suggested  by  other  authors: 
Edgar  Garceau,  of  Boston,  devised  a  ucav  catheter  for  the  female, 
Avhicli  can  be  introduced  Avith  the  aid  of  my  direct  cystoscope.     This 
catheter  is  35  cm.  in  length,  its  caliber  is  No.  13  Charriere,  from  the 
external  end  to  its  center,  and  from  this  point  on  the  diameter  becomes 
smaller  gradually  and  progressiA^ely  up  to  the  ureteral  end,  Avhere  its 
diameter  is  No.  6  Charriere. 


Fig.  192.— Ure- 
teral catheter 
within  a  ureter. 
One  can  easily 
see  how  the  urine 
trickles  down  be- 
tween the  cathe- 
ter and  the  ure- 
teral   wall,    Ji.w. 


CATHKTKRI/ATION    OF    TTIE    URETERS 


303 


Tlic  ureteral  tip  of  tlie  eathetei-  is  like  lliat  ol'  a  flute;  at  each  side 
of  the  instruiueut  soiuewliat  removed  tVom  the  extremity,  tliere  are  two 
eyes  opposite  one  another  to  facilitate  the  urinary  flow.  Its  intro- 
duction is  extremely  simple.    First  a  stylet  is  inserted  into  the  ureter 

through  Luys'  cystoscope  and  the  catheter  is 
then  advanced  over  the  stylet;  inserting-  it  into 
the  ureter  is  an  easy  matter  because  these  ma- 
neuvers are  carried  out  under  direct  control  of 
the  e^^'e. 

The  advantages  of  this  instrument  are, 
first,  the  certainty  that  the  total  quantity  of 
urine  secreted  will  be  collected,  because  the 
catheter  obstructs  the  ureteral  canal  in  exactly 
the  same  manner  as  a  stopper  corks  the  neck 
of  a  bottle.  Secondly,  the  facility  with  which 
it  can  be  introduced;  this  is  owing  to  the  fact 
that  the  ureteral  extremity  has  a  much  smaller 
caliber  than  that  of  the  ureter  itself. 

Gudin,  of  Rio  cle  Janeiro'^  has  adopted  still 
another  procedure,  in  order  to  obtain  occlusion 
of  the  ureteral  orifices.  He  accomplishes  ure- 
teral catheterization  with  a  conductor,  this  be- 
ing a  modification  of  the  ureteral  catheter  and 
stylet  previously  described  by  Albarran.*'  Us- 
ing an  indirect  vision  cystoscope,  Gudin  first 
introduces  graduated  whalebone  stylets  No.  4 
Charriere,  and  90  cm.  in  length,  the  extremity 
of  which  is  made  of  rubber,  so  as  not  to  injure 
the  ureteral  mucosa  and  possibly  cause  a  false 
passage.  Each  stylet  is  introduced  into  the 
ureter  for  a  distance  of  about  15  cm.;  then  the 
indirect  cystoscope  is  removed.  The  stylets 
are  now  left  in  place,  and  catheters  with  blunt 
ends  are  passed  over  them  into  the  ureter. 
The  catheter  is  passed  over  the  stylet,  the  pre- 
caution being  taken  not  to  exert  traction  on  the 
latter,  for  that  miglit  cause  it  to  drop  into  the 
bladder ;  then  holding  the  end  of  tlie  stylet  with 
catheters  whh^doubie'canais.'To  ouc  haud,  thc  Catheter  is  advanced  over  it  Avith 
l^:"i:^.::Zj'Z.:^::''Z  the  other  hand.  Finally  the  stylet  is  removed. 
t.b";r'wa^te;;'';;L\r.i,:;  The  ureteral  catheters  have  a  caliber  of  5 

ureiera'i'°waiL"''°''*'°"  ""'*''  *''^     to  8  Charrlcre  for  a  distance  of  a  few  centi- 


D- 


Ha 


304  CYSTOSCOPY   AXD    URETHROSCOPY 

meters ;  then  they  dilate  progressively  up  to  No.  10  or  thereabouts. 
Thej^  maintain  this  diameter  ujd  to  the  funnel  end.  .The  tot£|^  catheter 
length  is  about  45  centimeters.  In  this  manner  it  is  possible  to  collect, 
to  a  certainty,  the  total  cpiantity  of  urine  eliminated  by  each  kidney. 

2.  A  second  source  of  error  is  found  as  a  result  of  the  passage  of 
the  catheter  into  the  ureter.  Without  mentioning  the  lesion  that  it 
may  produce  in  tuberculous  ureteritis,  for  instance,  a  catheter  may 
cause  bleeding  of  the  ureter  and  thus  simulate  a  hematuria,  that  does 
not  really  exist. 

On  June  8,  1904,  J.  AV.  Keefe,  replying  to  Kelly's  paper  at  the  meet- 
ing of  the  American  Urological  Association,  reported  seventy  cases  of 
ureteral  catheterization.  In  forty-two  cases  he  examined  the  urine  be- 
fore the  introduction  of  the  catheter,  in  order  to  determine  the  extent 
of  the  damage  caused  by  the  passage  of  the  catheter.  There  was  no 
damage  in  but  three  of  the  cases.  In  the  other  cases,  traces  of  blood 
and  albumin  were  found ;  part  of  the  blood  was  due  to  the  distention  of 
the  ureter.  In  thirteen  cases  h^^alin  casts  were  foimd;  nevertheless  in 
only  one  case,  were  hyalin  casts  found  before  the  passage  of  the  cathe- 
ter. He  considers  the  introduction  of  the  catheter  a  dangerous  pro- 
cedure, even  when  the  catheter  is  perfectly  aseptic. 

3.  The  third  source  of  error  arises  from  the  fact  that  although 
catheterization  is  usually  limited  to  the  diseased  kidne^^  the  urine  must 
be  likewise  collected  from  the  supposedly  healthy  kidney  via  the  blad- 
der. The  urine  of  the  kidney  thought  to  be  normal,  comes  into  the 
bladder  which  is  often  infected,  and  it  is  there  mixed  with  the  jdus  con- 
tained in  the  bladder;  in  such  circumstances  it  is  impossible  to  say 
whether  the  pathologic  elements  found  in  the  urine  are  derived  from 
the  bladder  or  from  the  supposedly  healthy  kidney. 

4.  The  fourth  source  of  error  lies  in  the  fact  that  we  are  not  abso- 
lutely certain  that  the  catheter  is  resting  properly  in  the  ureter,  when 
the  indirect  cystoscope  is  employed.  In  fact,  in  order  to  avoid  renal 
infection,  some  authors  recommend  the  introduction  of  the  catheter 
into  the  ureter  for  a  distance  of  not  more  than  two  or  three  centi- 
meters. Now,  if  that  is  done,  when  the  instrument  is  withdrawn  so 
that  the  catheter  alone  remains,  the  surgeon's  eye  can  no  longer  see 
Avhether  the  catheter  is  still  in  the  ureter,  or  has  dropped  into  the  blad- 
der. Keydel,  of  Dresden,  has  emphasized  this  fact"  and  adds  that  in 
these  conditions  one  can  never  be  certain  that  an  error  has  not  been 
committed. 

5.  The  fifth  source  of  error  may  come  from  the  abnormal  irrita- 
tion of  the  kidney,  due  to  the  mere  presence  of  the  catheter  within  the 
ureter.    The  secretion  of  this  kidney  may  thus  be  changed,  and  incor- 


CATIIKTKTIIZATIOX    ol"    THE    URETERS  305 

rect  coiicliisioiis  ;iiTi\<Ml  ;il.  I  have  on  scvci'al  occasions  o))S('i'V('(l  tliat 
upon  llic  iii1  rodiiclioii  ol'  a  callictci-  inio  1  ln'  iii-ctci',  a  very  distinct  reflex 
polyuria  was  immediately  i)i-o(lii<'e(|,  wiiicli  lasled  Cor  sonio  timo  and 
then  slowly  disappeared. 

This  phenomenon  was  well  illustrated  and  demonstrated  by  Frank, 
of  Berlin,^  at  the  German  Surgical  Congress,  in  1905,  in  these  words: 

"I  also  desire  to  say,  as  Israel  has  already  remarked,  that  very 
often  wlien  a  catheter  is  introduced  into  the  ureter  or  pelvis,  the  quan- 
tity of  urine  that  flows  into  the  bladder,  may  he  increased  or  diminished, 
so  that  the  findings  are  unreliahle,  Wlien  a  catheter  is  inserted  into 
the  ureter  or  pelvis,  the  sensitive  nerve  centers  whicli  control  the  renal 
secretion  are  naturally  irritated.  In  this  manner,  erroneous  results 
concerning  the  determination  of  kidney  function  within  a  certain  fixed 
period  of  time  are  ohtained. 

"To  clear  up  this  question,  I  have  made  a  series  of  experiments  on 
certain  individuals  subjected  to  identical  dietary  conditions.  First,  I 
catlieterized  the  ureters;  a  little  later,  and  under  the  same  dietary  con- 
ditions, I  performed  separation  of  tlie  urine  (Luys'  method).  I  found 
that  when  the  ureters  were  being  catlieterized,  the  work  performed  by 
the  kidneys  is  mucli  greater  than  when  the  urines  were  separated  by 
the  segregator.  *  *  *  *  *  This  is  strongly  confirmed  in  the  four  cases 
which  I  examined  particularly,  taking  into  careful  consideration  the 
quantity,  the  specific  gravity,  the  quantity  of  sugar  after  injection  with 
phloridzin,  and  the  variations  of  urea.  These  experiments  were  made  in 
individuals  whose  kidneys  did  not  present  any  pathologic  conditions. 

"In  one  case,  ureteral  catheterization  as  opposed  to  the  sejDarator, 
caused  a  spasm  of  the  kidney;  in  the  other  case,  it  provoked  a  profuse 
polyuria. 

"In  these  cases,  I  employed  Luys'  separator  exclusively,  this  being 
the  only  one  among  tlie  various  instruments  proposed,  which  I  con- 
sider practical." 

REFERENCES 

iKouznetzky:      Riissk.   Viacli.,    March   22,    190S,   No.    12.   pp.    402-404;    Jour.    d.   riiir.,    .Tuuo. 

1008,  i,  No.  ?,,  p.  292. 
2Catheliii:     Folia  Urolooiea,  March,  lOOS,  ii,  No.  1,  p.  02. 
•"'Tr.  Intcrnatimial  Mod.  Congress,   100.3,  Section  on  Urology,   y.   71. 
4Garce:ni:      P.orl.   klin.   Wchnschr.,    .June    8,    1910;    14th    Mooting   Assn.    franc,    d 'Urol..    1910, 

p.  59G. 
■■■'Gudin:     Prcsso  jncd.,  .July  Ifi,  1910,  p.  546. 
f-Albarran:      Tocliniciuo    du    catheterisme    cystoscopique    dos    ureteros.    Rev.    do    gynoc.    al)d., 

1897,  p.  474;   also  Intoriiational  Med.  Congress  of  Moscow,  1S97.  |i.  2is. 
'Keydol:      Boitriige   zur   funktionellen  Nierondiagnostik.  Contrallil.    t'.    d.    Krankli.    i1.    Harn-u. 

Sex.-Org.,  May  25,  1905,  xvi.  No.  5,  pp.  225-274. 
«Frank:      ?.4th  Congress,  held    in    llcilin.  Vrrliaiidl.   d.  dcuts.-ii.   (iosollscli.   f.  Cliir.,   April   2(!-29, 

1905,  pp.  72,  7.3,  74. 


"^06  CYSTOSCOPY   AND    URETHROSCOPY 

URETERAL  CATHETERIZATION  IN  CHILDREN 

This  can  be  effected  by  using  indirect  cystoscopes  of  a  smaller  size, 
but  the  visual  field  will  be  consideral)ly  reduced  necessarily.  For  this 
Treason,  it  is  advantageous  to  use  the  direct  vision  cystoscope. 

Rocher  and  Ferron^  have  emphasized  this  fact  in  an  interesting- 
article :  "Direct  vision  cystoscopy  is  always  possible,  even  easy,  in^ 
girls  over  five  years  of  age.  The  urethra  readily  admits  a  No.  40  tube, 
7  cm.  in  length,  and  although  the  visual  field  is  reduced,  the  short 
length  of  the  tube  makes  exploration  of  the  bladder  possible.  In  a  tol- 
erant bladder,  a  slight  Trendelenburg  position  is  sufficient  to  produce 
vesical  distention.  At  this  early  age,  this  modified  position  is  readily 
accepted. 

''In  young  girls,  the  bladder  does  not  differ  from  that  of  the  mature 
woman.  Although  the  interureteral  ligament  may  not  be  so  marked, 
we  have,  nevertheless,  seen  it  quite  distinctly. 

"The  ureteral  orifice  usually  admits  a  No.  6  or  7  catheter.  In  one 
of  our  patients,  neither  orifice  admitted  anything  but  a  very  fine  bougie. 
We  believe  that  this  condition  has  no  connection  with  the  age  of  the 
patient,  since  we  meet  it  in  the  adult,  as  well,  and  every  specialist  has 
noticed  it  in  some  of  his  cases. 

"We  have  frequently  employed  general  anesthesia,  not  because 
these  maneuvers  are  painful,  but  because  children  are  often  frightened 
on  seeing  our  instruments,  and  thus  become  unmanageable. ' ' 

REFERENCE 

lEocher  and  Ferron:      Tuberculose  renale  chez  1 'enfant,  Jour,  d 'Urol.,  1913,  i,  p.   153. 


CHAPTER  VIII 

INFORMATION  DF.RIVED  THROUGH  URETERAL 
CATHETERIZATION 

INDICATIONS  FOR  URETERAL  CATHETERIZATION 

Catlieterization  of  tlie  ureters  should  be  reserved  exclusively  foi- 
ox])loralion  of  the  iireter  and  the  renal  pelvis.  For  a  complete  consid- 
eration of  ureteral  catheterization  and  the  functional  tests  of  the  kid- 
neys, the  reader  is  referred  to  a  separate  work  on  this  subject  by  the 
author/  In  the  present  chapter,  we  shall  therefore  consider  only  the 
data  furnished  by  catheterization  of  the  ureter  and  pelvis. 

Exploration  of  the  Ureter 

Ureteral  exploration  will  reveal  two  principal  pathologic  condi- 
tions of  this  canal;  i.e.,  stricture  or  obliteration,  and  calculi. 

A.  Stricture  or  Obliteration. — The  difference  between  a  stricture 
and  an  obliteration  of  the  ureter,  is  not  of  great  importance  in  the  pres- 
ent connection.  The  fine  ureteral  catheter  which  is  arrested  at  a  cer- 
tain spot,  indicates  in  the  simplest  possible  manner  the  exact  location 
of  the  stricture,  kink,  or  obliteration. 

Ureteral  strictures  are  recognized  by  the  fact  that  a  fine  catheter 
will  advance  beyond  a  certain  point  at  which  a  larger  catheter  is  ar- 
rested. Ureteral  obliterations,  on  the  other  hand,  arrest  all  catheters 
at  a  given  point,. however  fine  they  may  be.  The  location  of  this  jDoint 
can  be  determined  by  measuring  the  exact  length  of  catheter  that  has 
been  introduced  into  the  ureter. 

B.  Detection  of  Ureteral  Calculi. — Searching  for  a  calculus  with 
the  aid  of  the  ureteral  catheter  results  in  very  valuable  information. 
When  the  catheter  passes  alongside  of  a  calculus  embedded  in  the  ure- 
teral wall,  a  distinctly  characteristic  grating  sensation  can  be  felt. 

I  have  personally  observed  a  case^  in  a  man,  aged  thirty-nine  years, 
who  consulted  me  on  November  29,  1907,  l)ecause  of  numerous  attacks 
of  renal  colic;  sometimes  the  attacks  were  on  the  right  side,  at  other 
times  on  the  left,  and  they  extended  over  a  period  of  nine  years.  I 
catheterized  the  left  ureter  with  a  No.  7  catheter,  through  my  direct 

307 


308 


CYSTOSCOPY    AND    URETHEOSCOPY 


vision  cystoseo23e.  The  catheter  advanced  to  the  renal  pelvis,  but  Avhile 
I  was  withdrawing  it  slowly,  I  distinctly  felt  a  sensation  of«»gTating. 
PajDiDa,  an  intern  of  the  HosiDital,  who  was  iDresent,  observed  the  same 
sensation.    The  diagnosis  of  a  calcidus  seemed  to  be  well  founded. 

Though  radiography  was  negative,  the  patient  passed  two  stones, 
each  twice  the  size  of  a  bean,  nine  days  later.  To  make  sure  that 
these  stones  were  identical  with  those  felt  ■with  my  catheter,  I  catlie- 
terized  him  again  on  December  13,  1mt  did  not  observe  any  sensation 
of  friction. 

Kelly,  of  Baltimore,'  published  reports  of  38  cases,  and  has  re- 
jDcatedly  emphasized  the  importance  of  this  method  in  searching  for 
ureteral  calculi.  For  this  jourpose  Kelly  covers  his  catheter  tip  with  a 
coating  of  oil  and  wax,  j^repared  as  follows:  Olive  oil,  100  parts,  dental 
wax,  200  parts. 

The  tip  of  the  catheter  is  plunged  into  tliis  solution  wliile  it  is  still 


Fig.   194. — Wax-tipped   catheters   bearing   the    scratch   marks    of   a    calculus    (Kelly). 

slightly  warm,  and  then  permitted  to  cool  in  the  air.  The  catheter  thus 
acquires  a  polished,  smooth  and  very  delicate  surface.  The  greatest 
care  must  be  taken  to  deposit  this  coating  miiformly  over  the  catheter, 
so  that  there  will  l)e  no  appreciable  roughness  or  unevenness  on  its  sur- 
face. 

This  procedure  will  not  only  show  the  presence  of  a  stone,  but  also 
its  size  as  well.  The  deepest  scratch  marks  are  made  by  stones  embed- 
ded in  the  ureteral  wall,  and  wliich  can  be  neither  moved  nor  extracted. 

Considerable  difficulty  is  encountered  in  determining  the  exact 
location  of  the  calculus.  To  obtain  this  information,  Kelly  resorts  to 
the  method  described  by  SamiDSon,  namely,  of  depositing  at  intervals 
on  the  length  of  the  catheter,  a  series  of  small  olivary  masses  of  wax. 
T\lien  all  these  wax  olives  present  an  uninterrupted  scratch  line,  we 


INDICATIONS    KOi;    rKKTEHAL    CATTIETEUI/ATIOX 


300 


"lay  l)('  ccrlaiii  we  aiv  dcaliti-  \\i1li  a  urcUTal  sloiio.  On  Die  other 
liaiid,  llic  (listaiicc  Ix'twccMi  tlic  stoiK-  and  tho  pelvis  can  I)c  dctcrniiiicd 
l>y  incasiinii-  th,.  Icii-lh  ol'  Ww  scraldi  iiiai-k;  and  in  Hm'  same  niaiiiior 


M^^J 


Fig.    195. — Ureteral    calculi 


llie  distance  from  tlie  calculus  to  the  ureteral  orilice  can  also  be  easily 
determined. 

Kelly  indicates  the  ^Jossible  sources  of  error  with  this  procedure: 


PLATE  XX 

Fig.  1. — Inflammatwn  of  the  Madder  neck.  On  the  floor  are  seen  enormous 
edematous  and  hemorrhagic  masses,  which  could  be  revealed  only  by  the 
direct  vision  cystoscope.  It  is  readily  seen  how  these  edematous  masses, 
as  the  result  of  their  evolution,  can  tend  to  the  development  of  small 
papillomata,  such  as  are  illustrated  in  Plate  XVII. 

Fig.  2. — Localized  abscess  of  the  bladder  necTc.  In  this  case,  continuous 
recurrences  of  an  obstinate  urethritis  were  cured  only  as  a  result  of 
incision  of  the  abscess  with  the  galvanocautery. 


Fig.  1. 


Fig.  2. 

PLATE  XX 


INDICATIONS   FOR   URETERAL   CATHETERIZATION  311 

1.  Friction  of  the  waxed  tij)  with  the  cystoscopic  tube.  In  this 
case,  a  flat  and  uniform  depression  is  obtained,  instead  of  a  scratch  line 
which  a  stone  produces. 

2.  When  the  catheter  is  withdrawn,  care  must  be  taken  not  to  per- 
mit it  to  come  in  contact  with  the  pubic  hair,  which  might  impress  a 
deceptive  scratch  mark  on  the  wax. 

3.  The  catheter  should  be  inspected  thoroughly  before  it  is  intro- 
duced, to  be  assured  that  it  is  perfectly  smooth  throughout. 

In  spite  of  these  possible  shortcomings,  this  procedure  seems  to  be 
an  excellent  one.  In  renal  calculi,  however,  it  may  fail ;  exact  informa- 
tion can  not  be  obtained  when  the  renal  pelvis  is  considerably  dilated, 
or  when  the  stone  is  small;  and  when  the  calculus  is  lodged  in  cavities 
in  the  substance  of  the  renal  parenchyma,  the  waxed  tip  is  of  no  prac- 
tical value  whatever. 

Another  method  which  seems  to  avoid  these  disadvantages,  was 
recommended  by  Follen  Cabot.*  This  author  attached  the  free  end  of 
the  ureteral  catheter  to  a  stethoscope,  or  better  still,  a  phonendoscope. 
He  also  placed  a  smooth  metallic  stylet  in  the  interior  of  the  catheter, 
one  end  protruding  slightly  through  the  eye  of  the  catheter.  The  slight- 
est contact  between  a  stone  and  the  tip  of  the  metallic  stylet,  will  be 
distinctly  heard  by  the  observer  with  the  phonendoscope.  According 
to  this  author,  not  only  can  the  presence  of  a  stone  be  detected  with  this 
method,  but  also  its  exact  location  in  the  ureter  or  the  pelvis. 

The  ureteral  catheter  detects  the  presence  of  calculus  in  the  ureter; 
but  when  the  stone  is  situated  in  the  lower  part  of  the  ureter,  it  can  also 
be  extracted  with  the  aid  of  my  cystoscope.  The  following  case  illus- 
trates this  point  nicely: 

A  woman,  aged  thirty-one  years,  in  the  service  of  Pozzi,5  had  a  calculus  in  the  right 
ureter;  its  presence  was  confirmed  by  a  radiogram  made  by  Infroit,  and  also  by  vaginal 
examination.  Ureteral  catheterization  with  the  direct  cystoscope  showed  that  all  catheters 
were  arrested  at  two  centimeters  from  the  ureteral  orifice.  A  series  of  progressive  ureteral 
dilatation  was  instituted,  using  flexible  metallic  bougies,  Nos.  8,  10,  12,  and  even  No.  16 
Charriere.     In  this  manner,   I  succeeded  in  obtaining  a  very  distinct  calcular  contact. 

To  increase  the  dilatation,  I  then  introduced  bougies  which  were  left  in  situ  in  the 
lower  end  of  the  ureter,  for  twenty-four  hours.  I  then  decided  to  attempt  the  extraction 
of  the  stone  with  a  foreign  body  forceps;  this  entered  the  ureter  easily  enough,  but  I  did 
not  succeed  in  grasping  the  stone,  nor  could  I  move  it  from  its  position. 

The  diagnosis  of  embedded  calculus  was  made,  and  verified  a  few  days  later,  on  opera- 
tion by  Pozzi.  He  did  a  subperitoneal  lateral  laparotomy  and  extracted  the  stone,  with 
considerable  difficulty.  It  was  found  completely  embedded  and  very  adherent  to  the  mucosa, 
.  a  fragment  of  which  came  away  with  the  stone.  In  this  particular  case,  it  can  be  easily 
seen  why  the  intraureteral  intervention  was  unsuccessful. 

Other  foreign  bodies,  besides  calculi,  can  lilvemse  be  extracted 
with  fine  forceps.    This  is  well  illustrated  in  the  case  fully  described 


312  CYSTOSCOPY    AXD    UEETHROSCOPY 

on  page  375.  [Repetition  of  the  details  of  this  case  lias  been  thought 
inadvisable  by  the  editor,  who  has  taken  the  liberty  of  merely«j'efeiTing 
to  it. — Editopv.] 

Another  useful  indication  for  ureteral  catheterization,  is  to  intro- 
duce a  catheter  into  the  ureter,  to  act  as  a  guide  in  operations  upon 
the  ureter  or  ujDon  adjacent  organs.  . 

KEFEPtENCES 

iLuys:      Exploration   de   I'appareil   urinaiie,   Paris,   Ma&sou,   1909,   eel.   2,   p.   519. 

2Luys:     Bull,  et  mem.  Soc.  de  cliir.  de  Paris,  Feb.  12,  1908,  p.  211. 

3Kelly:     My  Experience  with  the  Keual  Catheter  as  a  Means  of  Detecting  Renal  and  Ureteral 

Calculi.      Read   before   the   third    annual   meeting   of   the    American   Urological   Assn., 

June  8,  1904. 
4Follen  Cabot:     A  New  Method  for  Detecting  Calculi  in  the  Ureter  and  Kidney,  Am.  Jour. 

Urol.,  March,  1905. 
sPozzi:     Bull,  et  mem.  Soc.  de  chir.  de  Paris,  Feb.  26,  1908,  p.  286. 

Treatment  of  Nephritic  Colic 

This  most  useful  application  of  ureteral  catheterization  in  ne- 
phritic colic,  has  already  been  mentioned  above.  It  is  based  on  the  gen- 
erally accepted  theory  that  nephritic  colic  is  the  result  of  a  stone  which 
starts  from  the  renal  pelvis  and  becomes  engaged  in  the  ureter  on  its 
way  to  the  bladder. 

Formerly  the  usual  treatment  was  purely  medical.  It  consisted  in 
placing  the  patient  in  bed  and  the  administration  of  hypodermic  injec- 
tions of  morphine.  This  treatment  was  unquestionably  uncertain  and 
did  not  give  the  most  effective  results.  At  present,  ureteral  catheteriza- 
tion, properly  employed,  seems  to  be  the  most  desirable  method  of 
treatment.  We  may  properly  ask,  "Why  should  we  leave  this  task  to 
be  done  poorly  by  nature,  when  we  can  aid  her  materially  in  her  effort?" 

The  calculus  has  a  tendency  to  descend  along  the  ureter;  then  why 
not  encourage  this  tendency  and  facilitate  this  movement,  particularly 
when  the  stone  has  been  retained  for  some  time  or  even  may  remain 
indefinitely  in  the  ureteral  canal  because  of  some  roughness  of  its  sur- 
face? It  is  also  essential  to  avoid  at  any  cost  the  grave  complications 
like  hydronephrosis  and  consecutive  renal  infections  which  often  result 
from  the  retention  of  a  stone,  and  which  are  invariably  fatal  in  their 
consequences. 

The  following  history  of  a  case  is  particularly  typical : 

A  man,  aged  sixty  years,  who  had  been  in  the  habit  of  taking  his  annual  cure  at 
Contrexeville,  found  himself  unable  to  take  his  usual  treatment.  On  June  17,  1911,  while 
feeling  perfectly  well,  he  suddenly  felt  a  sharp  pain  in  the  right  kindey,  which  radiated 
down  the  ureter  toward  the  testicle,  and  had  all  the  characteristics  of  renal  colic.  Tliis 
condition  lasted  two  or  three  days  without  cessation. 


DETERMIXATinX    OF    rFJ.VIC    CAPACITY  616 

On  June  10,  BoIult,  wlm  was  attcMidiii^  him,  oliservcd  tliat  bimanual  palpation  of  the 
right  kidney  produced  a  constant  and  very  characteristic  pain;  also  that  rectal  examination 
provoked  a  sharp  pain  when  the  inferior  extremity  of  the  rij^ht  ureter  was  palpated.  Tlie 
patient  was  then  referred  to  me  for  a  cystoscopic  examination. 

I  found  the  bladder  perfectly  normal;  likewise  the  left  ureteral  orifice.  But  the  right 
ureteral  orifice  was  dilated  enormously;  the  vesical  portion  of  the  ureter  seemed  turgid,  in- 
flamed, and  dilated  so  that  it  resembled  the  neck  of  the  uterus.  This  was  highly  suggestive 
of  a  ureteral  lesion.  A  Xo.  G  catheter  penetrated  about  one  centimeter  into  the  ureter,  where 
it  was  arrested  for  a  few  moments,  during  which  time  it  was  noticed  that  pus  was  exuding 
from  the  ureteral  orifice.  After  a  few  attempts,  the  catheter  was  advanced  further  and 
we  found  that  there  was  an  undoubted  pyelitic  retention  of  about  33  c.c.  The  fluid  thus 
obtained  was  bloody  and  contained  blood  clots.  The  pelvis  was  irrigated  with  a  1:1000 
solution  of  silver  nitrate ;  and  while  the  catheter  was  being  withdrawn,  a  very  typical  and 
characteristic   friction   sensation   was   distinctly   felt. 

The  patient  went  home,  relieved  of  all  his  pains.  The  same  evening  he  voided  a  small 
stone  with  the  urine;  the  latter  became  clear  and  all  morbid  symptoms  disappeared. 

In  this  case,  therefore,  catheterization  produced,  an  excellent  result;  on  the  one  hand, 
it  relieved  the  patient  of  his  pains,  and  on  the  other,  it  prevented  the  usual  complications; 
i.  e.,  hydronephrosis,  pyonephrosis,  renal  infection,  etc. 

Exploration  of  the  Renal  Pelvis 

The  indications  for  the  exploration  of  the  pelvis  with  the  ureteral 
catheter,  may  be  summed  up  as  follows: 

1.  The  Detectiox"  of  a  Calculus  ix  the  Pelvis. — The  operative 
technic  is  the  same  as  that  for  ureteral  calculi;  full  details  have  been 
given  in  the  preceding  chapter. 

2.  To  CoxFiKM  A  DiAGxosis. — 111  difficult  cases  when  the  diagnosis 
is  doubtful,  it  is  not  known  whether  the  disease  is  located  in  the  kid- 
ney, or  in  surrounding  organs;  i.e.,  the  sijleen,  liver,  ovary,  etc.  In  such 
instances,  following  Kelly's  suggestion,^  it  is  Avell  to  catheterize  the 
ureter  and  distend  the  pelvis  with  a  fluid  injected  slowly.  A  slight  pain 
is  thus  produced,  and  when  the  patient  recognizes  this  pain  as  being- 
similar  to  his  usual  pains,  their  renal  origin  may  be  taken  for  granted. 

3.  To  Deteemixe  the  Capacity  of  the  Eex^al  Pelvis. — This  is  an 
extremely  interesting  subject,  which  has  not  yet  been  thoroughly  devel- 
oped. 

Determination  of  the  Pelvic  Capacity 

The  systematic  study  of  the  pelvic  capacity  enables  us  to  estimate 
the  degree  of  destruction  of  the  renal  parenchyma  and  also  furnishes 
definite  and  valuable  indications  as  to  the  surgical  measures  to  be  taken. 
In  cases  in  which  there  is  a  considerable  pelvic  dilatation,  there  must 
be  urinary  stagnation  or  suppuration,  the  amount  of  which  must  be  de- 
termined. If  this  suppurating  focus  is  considerable  in  quantity,  noth- 
ing but  nephrectomy  can  be  advised.     On  the  other  hand,  Avhen  the 


314  CYSTOSCOPY    AND    URETHKOSCOPY 

pelvis  is  but  slightly  dilated,  stagnation  is  limited  and  the  complete 
removal  of  the  kidney  is  therefore  not  indicated.  ^ 

Exceptions  must  be  made,  however,  in  renal  tuberculosis  and  neo- 
plasms. In  these  conditions,  when  the  diagnosis  of  tuberculosis  or  neo- 
plasm has  been  definitely  made,  nephrectomy  is  the  operation  of  choice 
with  the  vast  majority  of  surgeons.  But  in  other  conditions,  renal 
lithiasis  or  hydronephrosis,  for  example,  the  capacity  of  the  pelvis  is 
a  preponderating  factor  in  the  method  of  treatment  to  be  adopted. 

It  is  absolutely  essential  to  possess  precise  information  before  the 
surgeon  takes  his  knife  in  any  surgical  intervention  on  the  kidney. 
Some  surgeons  are  satisfied  with  clinical  symptoms,  or  with  the  find- 
ings of  the  kidney  exposed  on  operation;  but  these  are  really  not  wise 
procedures,  for  it  has  often  occurred  that  even  with  the  kidney  deliv- 
ered, the  surgeon  has  been  unable  to  determine  Avhat  was  wrong  with  it. 
It  is  therefore  far  more  rational,  more  definite  and  more  prudent,  to 
examine  the  patient  methodically  so  as  not  to  operate  blindly,  but  ac- 
cording to  exact  information  acquired  beforehand. 

Techi^ic  of  the  Determinattox  or  the  Pelvic  Capacity 

The  catheter  is  introduced  into  the  ureter  and  up  to  the  pelvis,  and 
left  there  for  a  few  moments,  during  which  time  the  urine  flows  normal- 
ly. Then  the  patient  is  placed  in  the  horizontal  position.  A  graduated 
syringe,  filled  with  boric  acid  solution,  is  attached  to  the  catheter  and 
the  fluid  injected  very  slowly  and  carefully,  meanwhile  instructing  the 
patient  to  announce  when  he  feels  the  slightest  sensation  of  pain.  In 
the  normal  case,  this  pain  appears  suddenly  as  soon  as  about  five  c.c. 
have  been  injected.  If  the  injection  is  not  made  very  slowly,  extremely 
violent  pains  may  result. 

The  advantages  of  this  procedure  may  be  realized  from  the  follow- 
ing case  histories: 

Case  1. — M.  S.,  male,  aged  fifty-six  years,  was  referred  to  me,  on  July  1,  1905,  by 
Suarez  de  Mendoza,  of  Madrid.  Thirty  years  previously  he  had  had  several  attacks  of  right 
renal  colic,  which  culminated  in  the  expulsion  of  small  calculi. 

He  was  perfectly  well  up  to  two  and  a  half  years  ago,  when  he  was  suddenly  seized 
with  severe  pains  on  the  left  side,  followed  by  hematuria  of  renal  character.  At  times  the 
urine  was  clear,  at  other  times  bloody.  Six  months  ago,  the  hematuria  ceased  and  the  urine 
became  purulent. 

On  examination  the  urine  was  found  purulent.  Guinea-pig  inoculation  done  some 
time  previously,  v/as  negative ;  the  animals  gained  in  weight  and  were  in  excellent  health 
since  the  inoculation. 

The  urethra  is  free,  the  bladder  has  an  excellent  capacity,  and  the  kidneys  can  not 
be  palpated. 

Urinary  separation  was  easily  accomplished,  with  this  result :  On  the  right  side,  the 
urine  is  normal  and  flows  in  rhythmic  and  regular  ejaculations;  on  the  left  side,  the  urine 
is  foul  and  cloudy,  and  flows  continuously  drop  by  drop. 


DETERMINATIO]^    OF   PELVIC    CAPACITY 


315 


Chemical  analysis  shows  the  following: 


RIGHT   KIDNEY 

LEFT  KIDNEY 

MIXED     (BLADI 

Quantity 

8.7  c.c. 

8.6  c.c. 

Freezing 

point 

-1.48° 

-0.72° 

-0.20° 

Urea  per 

1000 

c.c. 

14.12  gm. 

6.55  gm. 

12.88  gm, 

NaCl 

8.50    " 

5.00     " 

8.50    " 

Index     oi 

:     refi 

rac- 

tion 

1.340,822 

1.336,670 

1.338,960 

Microscopic  Elements 

Principally  pus  and 

Solely  pus 

Sediment 

1.  Numerous     red 
blood  cells; 

2.  Polynuclear     leu- 
cocytes,   much    in    ex- 
cess     of     the     white 
blood    cells,    but    con- 
siderably less  in  quan- 
tity  than   on   the   op- 
posite side; 

3.  Bladder  cells. 

a  few  bladder  cells. 

The  diagnosis  was  clear:  Left  pyonephrosis  with  sufficient  function  of  the  right 
kidney.  The  necessity  of  surgical  intervention  on  the  left  kidney  was  imperative ;  but 
what   was   the   particular   operation   that   was   indicated? 

To  answer  this  question,  I  catheterized  the  left  ureter  on  July  8.  The  pelvic  capacity 
in  three  different  tests,  was  fifteen  c.c.  each  time.  This  showed  that  the  pelvis  was  but 
little  dilated  and  that  the  renal  parenchyma  was  but  slightly  damaged.  Consequently 
nephrectomy  was  rejected,  and  nephrotomy  decided  upon. 

The  patient  was  referred  to  Beclere,  for  a  radiogram,  which  revealed  the  presence  of 
calculi  in  the  left  kidney. 

These  three  successive  examinations  therefore  gave  us  the  following  data:  The  seg- 
regator  showed  a  left  pyonephrosis ;  catheterization  showed  little  pelvic  dilatation  and  slight 
parenchymatous  destruction;  and  the  radiogram  demonstrated  the  presence  of  calculi  in  the 
kidney. 

Nephrectomy  was  performed  by  de  Mendoza,  at  Madrid,  on  September  10.  He  found 
five  stones  in  the  pelvis  and  upper  portion  of  the  ureter. 

By  way  of  contrast  with  the  preceding  case,  the  following  case 
may  be  mentioned: 

Case  2.— H.  M.,  female,  aged  forty  years,  had  been  pregnant  fourteen  times ;  ten 
went  to  full  term  and  the  others  were  abortions.  Most  of  her  children  died  in  early  infancy. 
The  patient  now  has  but  two  living  children,  one  nine  and  a  half  years  old,  healthy,  the 
other  seven,  with  Pott's  disease.  Patient  had  measles  and  chicken  pox  in  her  youth;  other- 
wise she  was  always  well  up  to  her  twelfth  pregnancy,  when  she  had  attacks  of  hematuria 
and  aborted  in  the  fifth  month.  After  the  abortion  the  hematuria  ceased.  But  the  urine 
has  always  been  cloudy  since  then,  leaving  a  whitish  precipitate  on  standing. 

During  her  last  pregnancy,  when  she  was  two  and  a  half  months  pregnant,  she  en- 
tered the  maternity  ward  of  the  Saint  Antoine  Hospital,  in  the  service  of  Bar  (December 
11,  1903).  At  that  time,  the  urine  was  purulent,  with  an  abundant  white  deposit.  Micro- 
scopic examination  revealed  numerous  pus  cells,  but  no  blood  cells.  Bimanual  palpation 
of  the  left  kidney  revealed  that  it  Avas  painful  on  pressure  and  enlarged.  No  pain  over  the 
right  kidney,  nor  in  the  hypogastric  region. 

Separation   of   the   urines   was   perfornied   by   me   on   December   19,   and   showed   clear 


316 


CYSTOSCOPY   AND    UKETHROSCOPY 


urine  on  the  right  side,  and  purulent  urine  on  the  left.     Chemical  analysis  of  the  separated 
urines,  made  by  the  intern  of  the  pharmacal  service,  was  as  follows: 


Reaction 

Urea   (per  liter) 

Chlorides 


RIGHT   KIDNEY 

acid 

29.84  gm. 
9.00    " 


LEFT   KIDNEY 

alkaline 
2.56  gm. 
4.00    '' 


MIXED     (bladder) 

acid 
12.66  gm. 
8.00    " 


This   examination   showed   that   almost    all   the   urinary   depuration   was   being   done   by 
the  right  kidney. 


Fig.    196. — Calculous   pyonephrosis    (external   aspect). 

At  that  time,  the  patient  was  two  and  a  half  months  pregnant.  This  was  terminated 
in  the  sixth  month  by  an  abortion.  She  came  to  see  me  on  April  28,  1905,  presenting  a  large 
painful  mass  on  the  left  side;  it  moved  distinctly  with  the  respiratory  movements. 

The  left  ureter  was  catheterized  with  my  direct  cystoscope.  Nothing  came  through 
the  ureter  at  first,  but  after  bimanual  pressure,  a  flow  of  pus  appeared.  The  pelvic  capacity 
was  over  150  c.c.  On  May  4,  a  second  catheterization  gave  the  same  results,  and  the  patient 
felt  pain  only  when  150  c.c.  had  been  injected. 


l)ETERMINy\TlON    OV    PELV[C    CAPACITY 


3r 


T'lic  ovidoiK'o  ill  tliis  cMse  \v;is  clear.  Wo  were  deuliiiw-  witli  an  eiionrious  left  pyo- 
neplirosis;  tlie  renal  paienehyma  was  iiiueli  altered,  it  not  totally  destroyed;  nephrectomy 
was  clearly  indicated. 

This   was   done   on   May   23,    at   Laennee   Hospital.      The   kidney   was   enoinions    (Figs. 


Fig.  197  —Calculous  pyonephrosis.  The  calculus  !s  seen  in  the  center  of  the  pelvis,  and  is  illus- 
trated separately  m  the  lower  left  hand  corner  of  the  illustration.  The  pelvic  capacity  of  this  kidney 
was  over  ISO  c.c.  ^     j 

196  and  197).     It  was  irregular  in  shape,  its  walls  were  thinned,  the  parenchyma  converted 
into  a  purulent  sac;   at  the  hilum,  in  the  pelvis,  we  found  a  large  calculus. 

A  third  instance  seems  even  more  characteristic : 

Case  3. — A  woman,  aged  iifty-threc  years,  was  referred  to  me  on  November  15,  1905,  by 
Gaston  Alexandre.  She  complained  of  having  had  cloudy  urine  for  over  a  year;  occasionally 
she   had   henuituria   aggravated   by   walking   or   riding,   and    disnppearing   under   the    intiuence 


318 


CYSTOSCOPY    AND    URETHROSCOPY 


of  rest.     She  also  had  a  slight  increase  in  urinary  frequency, — every  two  hours  by  day,  and 
three  times  during  the  night. 

On  examination,  the  urine  is  cloudy,  with  a  heavy  deposit;  the  bladder  seems  to  be 
normal ;  its  capacity  is  over  250  c.c. ;  irrigation  is  easy,  the  fluid  coming  out  clear  rather 
quickly.  Palpation  of  the  kidneys  .is  negative;  neither  organ  can  be  felt;  there  is  no 
ureterovesical  reflex. 

Separation  of  the  urines  showed  that  the  urine  from  the  right  kidney  flowed  with 
regular  and  rhythmic  ejaculations,  and  was  perfectly  clear;  from  the  left  kidney,  the 
urine  was  very  cloudy.     Chemical  analysis  made  by  Maute,  showed  the  following: 


EIGHT   KIDNEY 

LEFT  KIDNEY 

MIXED     (bladder) 

Quantity 

11.8  C.C. 

10.2  c.c. 

Urea  per 

liter 

10.93  gm. 

11.92  gm. 

10.92  gm. 

Freezing  point 

-1.36° 

-1.40° 

-1.42° 

Index     of 

refrac- 

tion 

1.338,770 

1.338,998 

1.339,606 

Sediment 

1.  Some    red    blood 

1.  In     great     quan- 

1. Polynuclear     leu- 

cells,   with    occasional 

tity;    polynuclear   leu- 

cocytes abundant   (py- 

leucocytes (in  the  pro- 

cocytes, constituting  a 

uria). 

portion   of   blood   ele- 

dist i  n  c  t   microscopic 

ments). 

pjTiria. 

2.  Occasional     blad- 

2. In      small     num- 

2. Some   bladder 

der  epithelium. 

bers  in  the  same  pro- 

cells. 

3.  Crystals    of    oxy- 

portions  as  on  the  op- 

late of  lime. 

posite     side,  —  red 
blood  cells   and   blad- 
der cells. 

The  diagnosis  of  left  pyonephrosis  was  made.  To  determine  the  condition  of  the 
left  kidney,  the  left  ureter  was  catheterized  on-  November  21,  with  my  direct  cystoscope.  At 
that  time  the  patient  was  in  the  midst  of  an  attack  of  hematuria.  The  bladder  seemed  nor- 
mal, likewise  both  ureteral  orifices.  A  No.  7  catheter  was  introduced  up  to  the  kidney  and 
a  distinctly  bloody  urine  was  obtained.  At  the  same  time,  a  soft  catheter  (Nelaton)  placed 
in  the  bladder,  showed  that  the  urine  coming  from  the  opposite  kidney  was  clear.  A  second 
chemical  analysis  was  made  by  Maute  with  the  following  result: 


Quantity 
Freezing  point 
Urea  (per  liter) 


EIGHT    KIDNEY 

11  c.c. 

-1.62° 

12.73  gm. 


LEFT    KIDNEY 
7  C.C. 

-1.62° 
13.50  gm. 


Sediment 


Abundant  amorphous 
urates. 

Uric   acid   crystals. 

Fairly  numerous  red 
blood  cells,  about  ten 
times  as  many  as  on  the 
opposite  side. 

Also  bladder  cells. 


Very  many  red  blood 
cells. 

Very  many  polynuclear 
leucocytes,  constituting  a 
real   pyuria. 

Some  small  round  epi- 
thelial cells  from  the  kid- 
ney or  pelvis. 

Large  epithelial  cells 
in  round  heaps,  with  a 
large  nucleus,  and  which 
it  is  diflicult  to  localize. 

Numerous  cocci  ar- 
ranged in  pairs  and  in 
masses. 


DETERMINATION  OK  PELVIC  CAPACITY  319 

Tlic  Ifl'l  pchii-  ciiiiai'il  y  \\;is  ('(juihI  di  lie  liaii'ly  two  i-.c.  ;  1liis  sliuwcil  lliat  it  was 
nut  (listcjiilcil.  A  ia(li()<;r:im  was  made  liy  Jiecli-'ic,  wlm  slalcil  Ilia1  ''tlio  oxamiiial  inn  .if 
this  iiictuii'  (Idcs  iiiit   ^ivf  doriiiilc  ov'ulciu'o  of  tlic  jiicsciicc  (Ji-  alisriiiT  nf  a  stone." 

Conseqiiciitly  we  tliou^lit  we  liiul  a  case  of  sini|j|c  pyelitis.  Tlie  jielvis  was  iiri<^ate<l 
once  in  eis'l't  days  for  a  iiioiitli.  Tliesi'  iiii<;ations,  made  witli  a  1:1000  solution  f)f  silver 
nitrate,  immediately  stopped  the  hematuria  for  about  four  days,  after  which  period  it  re- 
appeared. Tlic  icsult  lu'iiij;  uiisat  isfadory,  an  opeiatioii  was  decided  iijion  after  eoiisulta- 
tion  with   AU'.xandre. 

Ill  ])()iiit  of  fact,  sejjaration  of  the  urines  poinlcd  lo  a  left  iiyoiicpiirosis ;  the  |jci\ii- 
capacity  demonstrated  there  was  no  dilatation.  Finally,  the  Iwo  (dicniicjil  analyses  indi- 
cated a  normal  functional  capacity  for  the  left  kidney. 

We  comduded  that  the  kidney  should  be  conserved,  and  decided  upon  a  neplirtjtomy. 
This  was  done  by  Alexandre  and  myself  on  January  27,  1906.  A  large  lumbar  incision  was 
made,  the  kidney  exposed,  and  through  the  external  surface  of  the  organ,  I  could  distinctly 
feel  the  presence  of  a  stone.  The  outer  margin  of  the  kidney  was  incised  and  the  parenchyma 
split  open  up  to  the  pelvis.  The  index  finger  introduced  into  the  pelvis,  easily  delivered  an 
extremely  large,  movable  calculus.  It  seems  very  hard,  is  12  mm.  in  length  and  11  mm.  in 
breadth.  The  ureter  seems  normal.  The  wound  was  closed  with  two  rows  of  catgut  sutures ; 
finally,  three  planes  of  sutures  for  the  muscular  and  superficial  layers.  Recovery  without 
incident.     Alexandre  saw  the  patient  again  two  years  later;   she  w'as  in  excellent  condition. 

It  can  therefore  be  seen,  from  a  study  of  these  three  cases,  that  the 
capacity  of  the  pelvis  should  be  known  definitely  before  resorting  to 
operation.    The  principal  advantages  of  this  procedure,  are  these: 

1.  In  renal  lithiasis,  hydronephrosis,  simple  nontuberculous  pyo- 
nephrosis, the  exact  knowledge  of  the  pelvic  capacity  will  determine 
whether  nephrotomy  or  nephrectomy  should  be  performed.  We  do  not 
pretend  to  say  that  this  method  of  diagnosis  is  the  only  one  to  decide 
this  question,  but  it  will  undoubtedly  contribute  materially  in  the  selec- 
tion of  the  operative  procedure. 

2.  "When  the  pelvic  capacity  is  found  greatly  increased,  and 
nephrectomy  has  been  decided  upon,  it  is  highly  important  that  this 
operation  should  be  performed  at  once,  without  preliminary  incision 
into  the  organ,  so  that  if  pyonephrosis  is  revealed,  the  kidney  can  be 
removed  in  its  entirety.  By  doing  this,  it  will  be  possible  to  avoid  in- 
fection of  the  wound  by  the  renal  pus,  and  will  permit  closure  of  the 
wound  by  primary  union;  this  occurred  in  our  Case  No.  2,  just  de- 
scribed. 

REFERENCE 

iKelly:      The  Use   of  the  Renal  Catheter  in  Determining   the   Seat   of   Obscure   Pain    in    the 
Side,  Am.  Jour.  Obst.,  1899,  xl.  No.  ?,. 

Ureteral  Catheterization  in  Kidney  Function  Tests 

In  the  performance  of  functional  tests  of  the  kidney,  the  role  of 
ureteral  catheterization  is  extremely  limited, — much  more  so  than  in 


320  CYSTOSCOPY    AXD    rRETHEOSCOPY 

the  exploration  of  the  ureters  and  pelvis;  and  it  should  ])e  employed 
only  in  such  cases  in  which  my  "urine  segregator"  can  notjDe  utilized. 

It  goes  without  saying  that  the  duality  of  the  renal  glands  necessi- 
tates a  double  analysis;  the  analysis  of  the  separated  urines  is  there- 
fore universally  accepted  as  a  matter  of  routine,  We  shall  not  empha- 
size this  point;  it  is  sufficient  to  say  tliat  this  important  idea  is  due  to 
the  unceasing  efforts  of  Albarran,  who  advocated  it  steadily  since  1897. 

Beyond  doubt,  the  simultaneous  ureteral  catheterization  continued 
during  twenty-four  hours  is  the  only  method  that  is  stricth^  and  abso- 
lutely exact.  This  is  indeed  an  ideal  theoretical  method,  but  in  actual 
j)ractice  it  can  not  always  be  carried  out. 

Xor  shall  we  enter  into  the  discussion  Avhicli  raised  such  violent 
polemics  between  the  advocates  of  my  "separator"  and  those  who 
favored  ureteral  catheterization.  This  Cjuestion,  which  will  be  the 
subject  of  another  work,  does  not  seem  to  be  within  the  scope  of  this 
book,  devoted  solely  to  the  study  and  consideration  of  vesical 
endoscopy.^ 

EEFEEEXCE 

iLuys :     Exploration  de  1  'appareil  urmaire,  Crowned  bv  tlie  Academy  of  Medicine,  Laborie 
Prize,  1907,  Paris,  Masson,  1909,  p.  430;   also,  Presse  med.,  Aug-ust  24,  1910,  p.  641. 

Treatment  of  Pyelitis  by  Pelvic  Lavage 

Lavage  of  the  pelvis,  studied  for  the  first  time  in  France  by 
Albarran  in  1898,  can  not  be  applied  in  every  case  of  pyonephrosis. 
In  renal  tuberculosis,  it  has  no  value  whatever,  and  moreover,  it  is 
absolutely  contraindicated.  Its  best  results  are  attained  in  the  milder 
types  of  pyelitis,  without  extensive  involvement  of  the  parenchyma. 
In  renal  lithiasis,  iDelvic  lavage  has  no  more  effect  than  bladder  irri- 
gation has  on  the  cystitis  which  accompanies  a  vesical  calculus.  To 
rejDeat,  then,  pelvic  lavage  is  of  service  only  in  the  mild  forms  of 
pyelitis. 

In  an  interesting  memoir  published  in  1904:,  Eafin,  of  Lyons,  has 
well  said  that  pelvic  lavage  is  efficacious  only  in  cases  in  which  there 
are  no  mechanical  obstacles,  because  in  such  cases  surgical  interven- 
tion is  absolutely  essential.  Lavage  may  be  utilized  as  palliative  treat- 
ment when  there  exists  a  contraindication  to  operation,  or  for  the  alle- 
viation of  local  or  general  symptoms  before  surgical  intervention. 
"When  pelvic  irrigation  is  followed  by  untoward  phen(^mena,  like  chills, 
or  a  rise  in  temj)erature,  it  must  be  discarded. 


PELVIC    LAVAfJE  321 

Techxic  of  Pelvic  Lavage 

For  lavage,  the  largest  possible  ureteral  catheter  must  he  em- 
ployed,— No.  7  or  8;  the  tip  should  be  flute-shaped,  and  should  bear 
two  lateral  eyes.  The  catheter  is  introduced  into  the  ureter  and  ad- 
vanced until  slight  resistance  is  felt.  At  this  moment  the  progress 
of  the  catheter  must  be  stopped  so  as  to  prevent  its  coiling  upon  itself 
within  the  pelvis.  The  ideal  position  of  the  catheter  is  with  its  ex- 
tremity at  the  entrance  of  the  pelvis,  just  as  a  vesical  catheter  should 
be  at  the  vesical  neck,  in  irrigation  of  the  bladder.  The  best  way  to 
determine  whether  or  not  the  catheter  is  properly  placed,  is  to  wait 
a  few^  moments  and  observe  whether  the  flow  of  urine  from  the  pelvis 
is  normal  or  otherwise.  If  the  catheter  is  advanced  too  far,  it  can 
easily  be  withdrawn  a  few  centimeters  toward  the  low^er  extremity  of 
the  pelvis ;  but  it  is  quite  difficult  to  push  it  forward  again.  In  practice, 
the  catheter  is  therefore  advanced  with  the  cystoscopic  tube  until  it 
begins  to  bend  on  itself  at  the  external  ureteral  orifice. 

The  cystoscope  is  no^v  withdrawn;  the  patient  is  placed  in  the 
full  horizontal  position.  When  the  urinary  flow  is  not  normal  it  is 
advisable  to  withdraw  the  catheter  one  or  two  or  even  three  centi- 
meters, at  the  most.  In  an  infected  pelvis,  irrigation  should  not  be 
begun  until  the  purulent  urine  has  ceased  flowing  under  manual  pres- 
sure; that  is,  when  the  drops  fall  from  the  catheter  slowly,  at  long 
intervals  and  without  force. 

Effective  lavage  is  attained  only  after  the  pelvic  mucosa  has  been 
cleansed  of  all  its  pus;  that  is,  when  the  boric  acid  solution  comes  out 
perfectly  clear.  To  obtain  this  result,  the  solution  is  injected  with  a 
syringe,  provided  with  a  fine  cannula,  that  can  be  fitted  tightly  to  the 
catheter.  The  injection  is  continued  until  a  slight  pain  is  felt  by  the 
patient  in  the  corresponding  hypogastrium.  The  piston  of  the  syringe 
is  pushed  very  slowly  and  gently  so  as  to  avoid  the  creation  of  any 
tension  in  the  pelvis;  this  might  bring  on  severe  pain  and  possibly 
syncope. 

The  quantity  of  fluid  thus  injected,  varies  according  to  the  indi- 
vidual patient;  sometimes  10  c.c.  are  sufficient,  while  at  other  times 
even  150  c.c.  are  insufficient  to  fill  the  pelvis  to  its  maximum  cajDacity. 

Evacuation  of  the  filled-up  pelvis  can  be  accelerated  by  slightly 
pressing  the  abdominal  wall  in  the  region  of  the  affected  kidney;  or 
the  patient  himself  may  assist  by  contracting  his  diaphragmatic  and 
abdominal  muscles,  as  in  coughing.     In  a  particular  case,  I  once  ob- 


PLATE  XXT 

Fig.  1. — Bullous  edema  of  the  vesical  fundus.  The  result  of  a  concomitant 
uterine  cancer,     ''Cushion"  appearance. 

Fig.  2. — Initial  pliase  of  the  invasion  of  the  vesical  fundus  by  cancerous 
infiltration  due  to  a  concomitant  uterine  cancer.  The  mucosa  has  a 
dark,  ecehj-motic  color,  and  in  various  places  jDresents  slight  hemor- 
rhages. 


Fig.  1. 


Fig.  2. 

PLATE  XXI 


iiK'i'i:i;.Mi.\.\'ri().\   oi-   i'i:r.\ic  cai'acitv  323 

served  lliat  tlic  in-i.unliiii;-  lliiid  (lowrd  (nil  of  the  catlie'ler  in  a  contin- 
uous .stream  as  a  residt  of  llic  ciTorts  made  by  the  patient. 

After  the  cleansing  irrigation  lias  Itccii  coinplcicd,  tlic  Ilici-ai)entie 
lavage  is  given,  the  following  solutions  being  connnonly  used: 

SoLUTio^^s  E.^rPLOYED. — A  1:1000  solution  of  silver  nitrate  has 
always  given  me  the  most  satisfactoiy  results.  Dilute  hydrogen  perox- 
ide invariably  gave  me  the  poorest  results.  It  decomposes,  producing 
numerous  gas  bubbles,  which  are  too  large  to  pass  out  of  the  ureteral 
catheter;  they  thus  inflate  the  renal  pelvis  and  ])roduce  considerable 
pain.  This  solution  should  never  be  employed.  Potassium  permanga- 
nate irrigations,  1 :4000,  also  give  good  results.  Oxycyanide  of  mer- 
curj' ,  1 :8000,  have  been  used  b}^  Feodorff.  Collargol,  2  or  3  per  cent, 
can  be  used,  but  Legueu  has  observed  infiltrations  and  infarcts  of  the 
renal  parenchyma  after  its  emi)loyment.  Aluminum  acetate,  1  per 
cent,  has  been  used  by  Kail.  [American  authors  seem  to  prefer  Argy- 
rol,  for  pelvic  lavage,  in  solutions  varying  from  5  to  25  per  cent. — 
Editor.] 

Frequency  and  Number  of  Irrigations. — These  vary  according  to 
the  individual  case.  They  depend  on  the  nature  of  the  infection,  the 
degree  of  pelvic  distention  and  a  number  of  other  concomitant  s^inp- 
toms.  On  the  average,  lavage  should  be  performed  about  two  or  three 
times  weekly,  depending  on  the  case.  In  the  great  majority  of  cases, 
once  a  week  is  usually  sufficient. 

In  some  cases  of  pyelitis,  excellent  therapeutic  results  can  be  ob- 
tained in  a  short  time,  after  two  or  three  irrigations.  I  have  seen  a 
very  interesting  case,  with  Abel  Desjardins,  the  patient  being  a  woman 
with  febrile  movements,  purulent  urine,  and  painful  right  kidney.  The 
patient  was  completely  cured  after  three  irrigations. 

In  other  cases,  pelvic  lavage  must  be  repeated  more  often  and 
carried  out  with  considerable  patience.  Kelly  catheterized  a  patient 
120  times  before  he  obtained  the  desired  result. 

Notwithstanding  the  fact  that  the  pelvis  may  have  been  thoroughly 
and  permanently  disinfected  through  lavage,  patients  should  be  kept 
under  careful  observation,  because  of  the  possibility  of  recurrence. 

When  this  method  of  treatment  is  unsuccessful,  it  is  usually  due 
to  an  existing  infection  of  the  renal  j^arenchyma. 

The  following  is  the  history  of  a  case  of  pyelonephritis  treated 
with  pelvic  irrigations: 

Ivight  Pyelonephritis  Treated  With  Pelvic  Lavaqc. — L.  CIi..  male,  aged  tliiity-five 
years,  presented  himself  on  July  17,  lOO.",  complaiiiino-  of  cloudy  urine  of  tliree  vcars'  dura- 


324  CYSTOSCOPY   AND    URETHROSCOPY 

tioii.  Some  time  previously  he  had  jjassed  urine  containing  red  sand,  but  since  then  his 
urine  became  cloudy  and  the  sand  had  not  reappeared.  His  general  condition  is  good,  no 
pain  on  urination,  no  increased  frequency,  but  has  a  constant  pain  in  the  isight  kidney 
region.  The  ureter  is  normal,  bladder  likewise,  with  a  capacity  of  over  450  c.c.  His  urine 
is  very  cloudy  and  contains  pus.  The  left  kidney  can  not  be  palpated ;  the  lower  pole  of 
the  right  kidney  is  slightly  perceptible. 

Urinary  separation  on  July  23,'  showed  scanty  and  cloudy  urine  on  the  right  side, 
abundant  and  slightly  hazy  urine  on  the  left  side. 

Chemical   anah'sis   made  by   Giraudeau,   was   as   follows: 

RIGHT   KIDNEY  LEFT    KIDNEY  :  MIXED     (BLADDER) 

Quantity  8  c.c.  28  c.c. 

Urea  (per  liter)  9.80  gm.  11.52  gm.  12.61  gm. 

This  result  proves  that  the  left  kidney  secretes  considerable  urine,  and  that  its  elimi- 
nating function  is  excellent;  while  the  right  kidney  secretes  little  urine  and  eliminates  poorly. 

Tlie  patient  being  in  good  general  condition,  is  put  on  a  regime  of  milk,  diuretic 
waters,  urotropin.     Under  this  regime  the  pains  diminished,  but  the  urine  is  still  cloudy. 

On  September  28,  general  condition  still  good.  In  October,  a  radiogram  was  taken 
by  Beclere,  with  negative  result.  On  January  11,  1904,  the  patient  is  still  in  good  condition, 
pain  has  .entirely  disappeared.  The  right  kidney  is  no  longer  palpable,  but  the  urine  is  still 
cloudy.     The  patient  remained  in  this  condition  an  entire  year. 

In  January,  1905,  he  came  to  see  me  on  account  of  the  persistence  of  cloudy  urine. 
At  this  time  the  patient  was  having  occasional  pains  in  the  right  lumbar  region. 

In  the  belief  that  the  right  kidney  function  was  good,  and  that  his  general  condition 
was  fair,  I  thought  that  pelvic  lavage  might  bring  about  good  results.  The  ureter  was  then 
catheterized  with  my  direct  cystoscope  on  January  19.  A  No.  7  catheter  was  left  in  place 
for  nearly  half  an  hour,  and  the  urine  thus  collected  was  analyzed  by  Maute,  with  this  result: 

Freezing  point  -1.01° 

Urea,  per  1,000  c.c.  9.20  gm. 

NaCi     "       "        "  6.50     " 

Sediment :     Leucocytes  in  large  number,  especially  polynuclear. 
Blood. 

Numerous  pelvic  cells. 

Very  many  microbes  (bacilli  and  especially  cocci, 
of  which  many  are  grouped  in  the  form  of 
streptococci)  but  which  it  is  impossible  to  dif- 
ferentiate by  direct  examination;  no  tubercle 
bacilli. 

The  pelvis  was  washed  freely  with  boric  acid  solution  and  then  with  1:1000  silver  nitrate 
solution.  Several  lavages  were  given  at  eight-day  intervals.  The  patient  informed  us  that 
on  the  day  when  the  lavage  was  given,  the  urine  was  very  cloudy,  but  that  it  became  much 
clearer  and  without  the  deposit  on  the  second,  third,  and  fourth  days  thereafter.  The  renal 
pains  disappeared  entirely  after  the  first  irrigation,  and  he  no  longer  felt  his  former  lumbar 
lassitude. 

At  any  rate,  this  direct  method  of  treatment,  though  not  absolutely  radical,  was  carried 
on  without  any  inconvenience  to  the  patient.  He  was  irrigated  in  the  morning  and  he  then 
attended  to  his  usual  occupation  the  rest  of  the  day  without  suffering  any  inconvenience. 

Ureteral  Catheterization — A  Demeure 

The  ureteral  catheter  left  in  situ  (a  demeure),  may  in  some  cases, 
facilitate  closure  of  a  lumbar  fistula.    I  have  seen  the  beneficial  results 


IMtKTKIIAI.    CA'I'IIK'I'KKI/A'I'IO.V A     HK.M  Kl '  KK 


325 


(>r  this  ])i-()C('(lur('  ill  scn-ci'jiI  Iiist.'iiiccs.  One  case  is  part  icularl)-  iiiler- 
esting-:  A  woman  willi  a  iifclci-al  stone,  i-esultiii.H'  in  anuria  and  serious 
,i;'eiiei"al  sxiiiploiiis.  Tlie  case  was  reporled  hefoi-e  the  Siiry-ieal  So- 
ciety.' 1  was  conij)elle(l  to  do  an  eiiier<^-ency  iiei)iirotoiiiy.  Tlioug-li  the 
patient  felt  l)ettei-  and  the  stone  had  l)een  removed  l)y  a  uretero- 
lithotomy, the  wound  did  not  close,  and  a  lumbar  fistula  persisted. 

A  No.  ^'2  catheter  was  iiit  i-()(hiced  throu'^li  my  cystoscope  and  left 
tliore.     ImmediatelN-  afterwai'd  it  was  found  that   tlie  kidiicv  l)anda<i-e 


M  p  --e  t 


Fig.    19S. — CoiiKenil:il    liydroncphrosis    resulting    in    an    nlidoniinal    renal     fistula. 

was  no  longer  being  soaked  with  escaping  urine,  and  it  remained  thus, 
absolutely  dry;  all  the  urine  from  the  left  kidney  was  being  collected 
l)y  the  ureteral  catheter.  The  latter  was  left  in  i)lace  for  seven  days, 
and  when  it  was  withdrawn,  tlie  ])atient  \-oided  urine  al)undant]v 
through  the  natural  channels. 

In  another  case-  of  renal  fistula  cousecutiN-e  to  a  congenital  liy- 
dronei)lii-osis  infected  (hiring  the  course  of  typhoid  fevei',  I  tliought 
the  fistula  might  close  and  the  normal  function  of  the  kidnev  might  be 
established  by  the  introduction  of  a   i)ermaiient  catheter   in   tlie   cor- 


326  CYSTOSCOPY    AXD    URETHROSCOPY 

responding  ureter.  I  therefore  inserted  a  No.  6  catlieter  but  quickly 
clianged  it  to  a  No.  9.  Because  of  its  large  caliber,  the  latter  could  be 
introduced  only  with  the  aid  of  my  direct  cystoscope;  in  point  of  fact, 
no  other  catheter  could  bring  about  the  desired  result. 

Drainage  was  poor,  because  very  little  urine  came  through  the 
catheter.  On  the  other  hand,  all  the  fluid  injected  through  the  catheter 
came  out  immediately  through  the  abdominal  fistula.  Because  of  this 
failure,  I  performed  nephrectomy,  and  this  was  followed  by  the  most 
satisfactory  results.  Figure  198  shows  clearly  that  we  were  dealing 
with  an  infected  congenital  hydronephrosis. 

In  true  pyonephrosis,  evacuation,  and  regular  drainage  of  the 
pelvis  can  be  accomplished  neither  by  pelvic  lavage  nor  b}"  the  perma- 
nent catheter.    Surgical  intervention  is  absolutely  imperative. 

In  aseptic  uronephrosis,  permanent  catheterization  is  also  inef- 
fective, because  the  catheter  will  inevitably  infect  the  uronephrotic  sac. 
In  calculous  anuria,  catheterization  can  be  recommended  when  it  can 
be  done  quickl}-  and  easily.  Krebs'  succeeded  in  displacing  a  stone 
and  provoked  diuresis  by  injecting  glycerin  into  a  ureter, 

EEFEEElSrCES 

iBull.  et  mem.  Soc.  de  ehir.  de  Paris,  Feb.  15,  1913,  p.  212. 

2Luys:     Fistule  renale  abdominale  consecutive  a  uiie  hydrouephrose  congenitale  infectee  an 
conrs  d'une  fievre  typlioide,  Neplirectomie,  Guerison,  La  Cliniqne,  Ang.  16,  1912,  p.  517. 
sKrelis:     Zur  Tlierapie  der  Aunria  Calculosa,  St.  Petersb.  med.  Wclinsclir.,  Xo.  52. 

Radiography  of  the  Ureteral  Catheter 

De  Ilyes^  first  suggested  the  introduction  of  a  flexible  metallic 
wire  into  the  ureteral  catheter  in  order  to  determine  any  abnormality 
in  the  direction  of  the  ureter,  or  to  locate  the  site  of  an  obliteration 
in  its  lumen.  A  radiogram  is  then  made,  and  the  catheter,  opaque  to 
the  roentgen  rays  is  seen  perfectly  in  the  photographic  plate. 

A  very  simple  expedient  is  to  place  fine  silver  threads  in  the 
catheters.  At  present  such  opaque  catheters  are  being  manufactured; 
they  contain  a  substance  in  their  texture  which  stops  the  x-rays,  thus 
making  them  visible  in  the  plates. 

EEFEREiSiCE 

iDe  lives:     Ann.  des  nial.  dcs  organes  geuitorinaires,  1902,  p.  335.  ' 

Pyelography 

Voelcker  and  Lichtenberg,  combining  ureteral  catheterization  with 
radiography,  injected  a  seven  |)er  cent  solution  of  collargol  into  the 


PYELOGIIAPIIY  327 

iiniioi-  and  pclxis  1  liroii- li  a  iirclcral  callictci-.  In  lliis  (-oiHlition,  a 
radiooTniii  is  fakcii.  'riic  jjclxis  tliiis  (lislcndcd  l.y  llic  collaryol,  gives 
a  \-('r\-  dcliiiiic  ])i('1ui-(".     This  mdliod  is  known  as  pNclo^i-apliy. 

This  procediiro  is  coinplcincid  to  llic  dctci-iiiination  of  llic  capacity 
of  the  pelvis.  Tt  is  evident  that  iiicasui-einciit  of  tlie  jjelvic  capacity 
when  pro])erly  ])erformed,  sliows  (piickly  and  distinctly  the  degree  of 
distention  and  the  extent  of  the  Jiydronephrosis.  But  wlien  we  desire 
corroboration,  by  the  aid  of  a  photographic  picture,  which  makes  a 
stronger  impression  on  the  eye,  it  is  evident  that  ])yelograi»hv  may 
render  excellent  service. 

Krotoszyner/  of  San  Francisco,  uses  solutions  of  cargentos  in- 
stead of  collargol.  A  25  per  cent  solution,  according  to  this  author,  is 
absolutely  without  danger,  but  he  opposes  the  use  of  a  50  per  cent 
solution  on  the  ground  that  it  may  irritate  the  upper  urinary  tract. 

This  author  places  the  patient  in  the  partial  Trendelenburg  posi- 
tion, injects  the  silver  solution  into  the  pelvis,  and  immediately  makes 
the  radiogram.  He  has  obtained  very  exact  information  from  the 
viewpoint  of  possible  surgical  intervention,  through  the  use  of  this 
procedure.    One  of  his  cases  is  particularly  interesting: 

A  gardener,  aged  forty-one  years,  suffered  constantly  fioni  left  neiiliiiti'^'  colic;  pyelog- 
raphy made  possible  the  diagnosis  of  a  marked  hydronephrosis.  Nephrectomy  confirmed  this 
diagnosis ;  the  origin  of  this  condition  is  of  unusual  interest.  During  the  decortication,  marked 
adhesions  were  found  at  the  upper  pole  of  the  kidney;  these  adhesions  consisted  of  abnormal 
blood  vessels,  which  completely  enveloped  the  ureter. 

This  interesting  case  corroborates  my  opinion-  that  one  of  the 
principal  causes  of  hydronephrosis  is  the  pressure  at  the  inferior  pole 
of  the  kidney  of  abnormal  l)lood  vessels  coming  directly  from  the 
aorta. 

Fraidv  Kidd'  of  London,  who  published  an  interesting  work  on 
pyeloradiography,  particularly  recommends  this  method  of  investiga- 
tion as  a  preliminary  step  to  operations  on  the  kidney.  He  believes 
that  the  collargol,  cargentos,  and  other  solutions  employed,  always 
cause  a  certain  degree  of  renal  irritation,  and  adds  that  a  reallv  ])a in- 
less  agent  is  still  to  be  found. 

He  recommends  a  5  per  cent  or  7  per  cent  solution  of  collargol, 
injected  under  low  pressure.  According  to  this  autlior,  jjyeloradiog- 
raphy  should  be  done  only  by  those  cai)al)le  of  selecting  the  cases, 
that  is,  those  cases  in  wliich  an  exploratory  operation  would  (Uherwise 
be  necessary.  The  risk  is  much  K'ss  witli  this  method  than  with  an 
exploratory  opei'ation.  He  also  advises  strongly  against  the  practice 
recommended  bv  some  authors  of  filling  the  same  kidiu'\-  three  or  four 


328  CYSTOSCOPY    AND    URETHROSCOPY 

times  with  strong  solutions  (15  to  50  per  cent).  [American  urologists 
have  had  excellent  results  with  a  15  per  cent  solution  of  Tiiorium,  as 
suggested  by  Burns/  A  splendid  review  of  the  entire  subject  of 
pyelography  is  given  b}^  Braasch^  in  his  monograph  of  the  subject. — 
Editor.] 

references 

iMartin  Krotoszyner :     Value  of  Pyelography  in  the  Diagnosis  of  Hydronephrosis,  California 

State  Jour.  Med.,  Nov.,  1913. 
2Luys:     A  propos  de  la  pathogenie  et  du  traitement  des  hydronephroses,  Tr.,  10th  session,  Assn. 

fran^.  d'Urologie,  Paris,  1917,  p.  122. 
sKidd:     Pyeloradiography :     A  Clinical  Study,  Proc.  Roy.  Med.  and  Chir.  Soe.,  London,  1913, 

vii  (Surgical  Section),  pp.  16,  40. 
4J.  E.  Biurns:     Jour.  Am.  Med.  Assn.,  June  26,  1915,  pp.  2126,  2127. 
■■■'Braasch:     Pyelography,  W.  B.  Saunders  Co.,  1915. 


PKACTK^AI.  AI»PL1CATI()XS  OK  (*^■ST()S("()MV 

Thanks  to  the  improvements  brought  ahont  in  i-ecent  years,  cystos- 
cop\'  Jias  made  possible  an  admirable  view  of  the  mucous  membrane 
of  the  bladder;  but  its  limits  are  not  restricted  to  the  visual  examina- 
iioii  alone,  for  it  has  in  addition,  numerous  therapeutic  applications. 
Jf  the  mucosa  and  its  lesions  in  their  i)athologic  state  can  be  seen 
well,  a  suitable  therapy  can  be  arrived  at.  In  this  respect,  direct  vision 
c.ystoscopy  surely  shows  its  superiority,  for  it  enables  us  to  apply  the 
treatment  as  well  as  to  recognize  the  lesion. 

We  will  now  take  up  the  following  subjects  in  succession: 
The  treatment  of  vesical  tumors,  of  foreign  bodies  in  the  bladder, 
of  cystitis,  of  calculi  of  the  ureteral  extremity,  and  vesical  biopsy. 

TREATMENT  OF  BLADDER  TUMORS 

For  a  long  time  general  surgeons  and  specialists  have  been  trying 
to  work  out  a  precise  formula  for  the  treatment  of  vesical  tumors. 
Hitherto  suprapubic  cystotomy  alone  seemed  to  meet  this  indication; 
at  the  present  day,  however,  this  view  has  changed  entirely  because 
the  endovesical  treatment  of  these  tumors  has  come  to  be  considered 
first  and  foremost,  owing  to  the  great  progress  that  it  has  made. 

Indications  for  Suprapubic  Cystotomy. — Suprapubic  section  is  in- 
dicated only  wlieii  the  ('n(h)vesieal  method  can  not  be  applied  ;  i.  c,  w  hen 
tlie  urethra  does  not  allow  the  introduction  of  large  enough  instru- 
ments, or  when  the  size  of  the  tumor  to  be  extracted  is  too  great.  With 
this  method  there  is  an  abundance  of  light  and  space  to  work  in,  and 
consequently  large  tumors  with  large  bases  can  be  readily  reached. 

As  to  cancer  of  the  l)hi(ider,  when  llie  histologic  diagnosis  has 
been  well  established,  there  seems  to  be  no  particular  advantage  in 
excising  the  tumor  by  the  suprapubic  route,  unless  it  is  well  circum- 
scribed and  localized,  from  the  very  beginning,  hi  these  eases,  as  in 
all  cancel's,  the  affection  is  still  local  and  sliouhl  lie  rctnoNcd  1)\-  the 
suprapubic  route.  But  when  the  walls  of  the  bladder  have  already 
become  infiltrated  and  the  tumor  has  spread  widely,  it  seems  there  is 
nothing  to  be  gained  by  operating,  because  surgical  intervention  pre- 

329 


330  CYSTOSCOPY   Al^B    URETHROSCOPY 

cipitates  further  developments  in  the  growth,  much  more  rapidly  than 
the  natural  and  normal  evolution  of  the  disease  itself.  '*' 

The  results  obtained  in  the  treatment  of  vesical  cancer  suprapu- 
bicalh^,  with  or  without  resection  of  the  vesical  wall,  are  not  very  en- 
couraging, and  too  deceptive  to  advise  the  employment  of  this  always 
serious  method.  We  may  therefore  conclude  that  the  endovesical  treat- 
ment of  vesical  tumors  is  the  method  of  choice  and  that  the  suprapubic 
operation  should  be  applied  only  in  cases  in  which  the  preceding  method 
can  not  be  resorted  to. 

Endovesical  Treatment  of  Bladder  Tumors 

The  ideal  purpose  of  the  endovesical  treatment  of  bladder  tumors 
is  to  destroy  the  neoplasm  by  way  of  the  natural  channels  without  hav- 
ing recourse  to  the  surgical  opening  of  the  abdomen.  The  endovesical 
method  through  the  perfection  of  its  highly  specialized  instrumenta- 
tion has  won  the  approval  of  most  urologists.  Generally  speaking,  it 
may  be  said  that  this  method  can  be  applied  to  all  benign  tumors,  which 
are  not  very  large  or  widespread.  The  principal  indication  for  this 
method  will  therefore  be  found  in  small  papillomata.  At  the  present 
time,  it  is  considered  neither  rational  nor  reasonable  to  perform  a  supra- 
pubic cystotomy  for  a  small  vesical  papilloma,  and  even  for  larger 
papillomatous  masses.  The  endovesical  treatment  must  be  considered 
the  method  of  choice. 

As  regards  cancerous  tumors,  neither  the  endovesical  nor  the  su- 
prapubic method  may  be  considered  really  curative.  However,  the 
former  can  be  utilized  much  more  successfully  than  any  other  method 
of  treatment  as  a  palliative  measure.  When  the  cancerous  tumors  are 
accompanied  by  profuse  hemorrhages,  which  put  the  patient's  life  in 
jeopardy  by  their  frequency  or  profuseness,  it  is  of  immediate  benefit 
to  attempt  to  control  the  source  of  bleeding  by  direct  applications  of 
adrenalin  or  by  the  use  of  the  actual  cautery ;  but  it  goes  without  say- 
ing, this  treatment  is  only  palliative  and  symptomatic. 

The  endovesical  treatment  can  be  applied  by  various  methods,  each 
having  its  own  special  advocates.  These  are  as  follows:  Galvano- 
cautery,  the  cold  or  hot  snare,  electrocoagulation  and  sparking,  elec- 
trolysis and  radiotherapy. 

Galvanocauterization 

This  can  be  applied  in  two  ways;  i.e.,  with  the  indirect  vision 
cystoscope  (Nitze's  method)  and  with  the  direct  vision  cystoscope. 


TREATiMENT    OF    BLADDER    TUMORS  331 

1.  With  the  Indirect  Vision  Cystoscope  (Nitze's  Method). — The 
oiidovosical  treatment  of  bladder  tuiuors  hy  galvanocautei'izalion  has 
been  called  the  method  of  choice  by  Nitze,  and  iu  a  i-cmarkable  Avork, 
Wo'iDrieh,  of  Berlin,  has  taken  up  its  defense  eloquently. 

Xitze'  devised  a  sjDCcial  cystoscope  for  the  treatment  of  bladder 
{umors.  This  instrument  was  an  ordinary  cj^stoscope  covered  with  a 
metallic  sheet  movable  over  the  body  of  the  cystoscope.  Its  extremity 
was  slightly  curved,  with  a  galvanocautery  attached  to  its  concavity. 
This  galvanocautery,  spiral  in  shape,  was  made  incandescent  by  the 
passage  of  an  electric  current.  Over  and  behind  the  galvanocautery 
there  was  also  a  metallic  snare  which  could  be  used  either  hot  or  cold, 
its  operation  being  controlled  by  an  outside  wheel  and  shuttle-cock 
(Fig.  199).  The  whole  constituted  an  instrument  so  large  that  it  could 
be  inserted  into  the  male  urethra  only  with  great  difficult3^ 

The  ox)erative  technic  was  to  fill  up  the  bladder,  as  usual,  to  in- 


Nitze's    operating   cystoscope. 


troduce  the  instrument  according  to  the  usual  rules,  find  the  tumor  and 
apply  the  galvanocautery  directly  upon  it.  Sometimes  the  galvano- 
cautery was  used,  at  other  times  the  cold  or  hot  snare.  With  the  latter, 
masses  of  tumor  were  torn  otf  piecemeal  at  ditferent  sittings,  after 
which  the  tumor  base  was  cauterized  energetically  with  the  galvanocau- 
tery. The  pieces  of  tumor  were  left  in  the  bladder  to  be  expelled  later 
with  the  urine.  Bleeding  occurred  with  this  method,  but  these  hematu- 
rias never  assumed  a  serious  character ;  thej^  stopped  after  a  rest  in  bed. 
I  had  the  opportunity  of  witnessing  Nitze  use  his  instrument  on  a 
patient  in  Berlin,  and  I  was  convinced  his  instrumentation  was  dif- 
ficult and  complicated  even  in  the  hands  of  its  author. 

In  addition  this  method  had  a  serious  disadvantage.  The  o])era- 
tion  being  performed  through  the  fluid  which  distended  the  bladder, 
the  platinum  wire  of  the  cautery  had  an  imperfect  incandescence,  being 
immediately  cooled  by  the  presence  of  the  water.  Id  order  to  obtain 
the  total  destruction  of  the  tumor  bv  this  method,   it   was  therefore 


332  CYSTOSCOPY    AND    URETHROSCOPY 

necessary  to  employ  many  sittings.  Finally  another  difficulty  was 
encountered  in  maintaining  the  bladder  fluid  absolutely  tran?^parent  so 
as  to  be  able  to  make  an  exact  and  precise  application  of  the  current 
upon  the  vesical  tumor. 

However,  the  statistics  furnished  by  Weinrich"  of  the  applications 
by  Nitze  up  to  the  end  of  1904,  comprised  399  cases  of  bladder  tumor. 
Of  these,  177  were  malignant,  94  were  benign  and  128  could  not  be 
accurately  classified,  for  want  of  tissue  for  microscopic  examination. 

Of  101  papillomata  operated  upon  by  Nitze,  he  found  no  recur- 
rence in  71  cases,  recurrence  in  18  cases,  and  12  cases  were  lost  sight  of. 

Recently,  Marion^  attached  a  si3ecial  cautery  forceps  to  an  indi- 
rect vision  cystoscope  for  the  treatment  of  vesical  tumors,  but  its  dis- 
advantages are  the  same  as  those  of  Nitze 's  instrument;  that  is,  it  is 
complicated,  pieces  of  tumor  often  remain  adherent  to  the  lens  of  the 
cystoscope  thus  obliterating  the  operative  field,  the  vesical  fluid  must 
be  changed  frequently;  these  manipulations  complicate  and  prolong 
the  technic;  the  cauterization  being  made  in  water,  it  is  undoubtedly 
less  efficacious;  finally,  the  attack  on  the  tumor  is  always  indirect,  be- 
cause of  the  lenses  which  reverse  the  image,  a  fact  that  renders  the 
treatment  more  complicated  and  difficult. 

Nevertheless  this  method  can  be  utilized  in  special  cases  in  which 
direct  vision  cystoscop}^  can  not  be  done  easily;  for  instance,  when 
abdominal  plethora  prevents  the  unfolding  of  the  bladder  in  the  in- 
clined position  of  the  pelvis.  Direct  vision  cystoscopy  does  not  give 
good  results  in  stout  patients.  In  some  instances,  I  have  been  com- 
pelled to  prescribe  a  preliminary  reduction  cure  before  I  was  enabled 
to  bring  about  dilatation  of  the  bladder  in  the  inclined  position. 

REFERENCES 

iNitze:     Leliibuch  der  Kystokopie,  p.  352. 

sWeinrieh :      L  'Extirpation   endovesicale   des   tumeurs   de   la   vessie   au   moyeii   du   cystoscope 

opeiateur  de  Nitze,  Tr.  Assn.  frang.  d'Urol.,  1905,  p.  148. 
sMarion:     Presse  med.,  1910,  p.  961. 

2.  Galvanocauterization    with   the    Direct    Vision    Cystoscope. — 

Galvanocauterization  of  vesical  tumors  directly  under  the  eye  without 
the  interposition  of  an  optical  apparatus  and  through  a  tube  introduced 
through  the  natural  passages,  was  first  employed  b}^  Griinfeld,  of 
Vienna,  with  very  primitive  instruments.  But  this  author  has  paved 
the  way  to  an  extremely  interesting  therapeutic  method;  unfortunately 
it  is  not  sufficiently  well  known,  nor  is  it  used  frequently  enough,  but  it 
deserves  the  full  attention  of  urologists  because  of  its  simplicity  and 
efficiency. 


TKKA'r.MKNT    OK    I'.LA  Dl  (KI!    'ITMOKS  33o 

'^riicsc  \('ry  (|U,Mlili('S  of  siiiiplicil >•  jiikI  criiciciicy  ;i11  raclcd  iii\'  Mttcii- 
lioii,  ;ni(l  I  adoptc'd  this  method  nearly  ten  yc.-ii's  a.n'o;  I  hdicxc  I  have 
made  it  ically  ])i*actical  l)y  the  perfeclioii  of  the  techiiic  wliieli  I  have 
l)i-ou,i;hi  al)oui.  The  direct  vision  cystosc()])e  makes  jralvanocaiitei'iza- 
lioii  of  hhuhh'T  inmors  hoth  si]n])h'  and  ('ffieaeious.  With  this  nu-thod, 
owins;'  to  modern  im])rovements,  the  maiiipiihitions  made  directly  under 
the  eye  arc  carried  out  with  a])Solute  precision.  The  operation  is  per- 
formed in  an  air  medium  and  the  decree  of  cautei'ization  tlius  o])tained 
is  much  stroni^'er,  more  precise  and  moi'c  Ihoron.iiii  and  the  dni-alion  of 
the  a])i)licati()n  is  naturally  nuicli  shorter. 

Technic  of  the  End-ovesical  Treatment  of  Bladdeii  Tr.Moits   Wirn 
LuYs'  Operating  Cystoscope 

Before  proceeding  to  the  endovesical  treatment  proi)er,  it  is  well 
if  one  is  not  particularly  versed  in  the  use  of  the  direct  vision  instru- 
ment, to  begin  by  examining  the  bladder  carefully  with  an  indirect 
cystoscope.  The  latter,  having  a  large  visual  field,  makes  it  possible 
to  find  the  tumors  easily  and  to  obtain  an  exact  general  outline  of  the 
growth.  After  emptying  the  bladder  completely  with  a  catheter,  the 
patient  is  placed  in  position  with  the  pelvis  elevated.  This  done,  the 
direct  vision  cystoscope  with  its  elbowed  obturator  is  introduced;  the 
tip  of  the  obturator  is  then  straightened  and  withdrawn.  The  aspira- 
tory  tube  of  the  cystoscope  is  put  in  operation  and  the  lamp  introduced 
and  lighted. 

Following  the  indications  found  previously  by  the  inspection  of  the 
bladder  mucosa  with  the  indirect  cystoscope,  we  proceed  directly  to 
the  places  where  the  tumors  are  located.  The  cystoscope  is  advanced 
directly  upon  the  tumor  itself.  With  the  left  hand  holding  the  cysto- 
scope steadily  in  position,  the  right  hand  introduces  the  thermocautery 
and  places  it  in  contact  with  the  vesical  tumcn-.  The  current  is  then 
turned  on  and  the  tumor  is  seen  burning  under  our  eyes.  The  fumes 
resulting  from  the  burning  are  quickly  evacuated  by  the  air  current 
which  is  maintained  by  the  continuous  action  of  the  water  puni]). 

In  the  case  of  papillomata,  the  tumor  often  l)ecomes  attachcti  to  the 
galvanocautery  as  soon  as  the  platinum  wire  begins  to  get  red.  It  i)re- 
sents  a  picture  resembling  the  arms  of  an  octopus  clasping  the  wire. 
Then  we  feel  that  the  extremity  of  the  cautery  which  is  wedged  in  at 
first,  has  suddenly  ac<iuired  a  certain  frcedoni  of  nioNcnicnt,  and  if  the 
cautery  is  withdrawn  by  stopi)ing  the  current,  it  will  be  found  that  the 
instrument  is  covered  with  i)ainllomata,  which  can  be  burned  easily  in 
the  free  air  and  thus  destroyed  in  the  simplest  manner. 


334 


CYSTOSCOPY   AND   URETHEOSCOPY 


It  is  to  be  noted  that  vesical  tumors  are  absolutely  insensitive  and 
that  the  patient  feels  no  pain  whatever  under  the  action  of  liie  burning 
platinum  wire.  When,  however,  the  base  of  the  tumor  has  been  reached, 
the  patient  feels  a  distinct  burning  sensation.  This  is  an  important 
indication  to  stop  the  cauterization  and  thus  avoid  possible  perforation 
of  the  bladder. 


Fig.   200. — Destruction   by  burning  of   a  bladder   tumor   through   the  natural  passages,   done   under   control 
of   the   eye,   with   Luys'    direct  vision   cystoscope. 

.  By  operating  in  this  manner  all  possible  complications  can  be 
avoided.  At  present  I  am  using  the  galvanocautery  only,  having  given 
up  completely  the  use  of  forceps,  which  may  cause  hemorrhage  Avhile 
removing  pieces  of  the  tumor.  The  use  of  the  galvanocautery  handled 
carefully,  renders  the  destruction  of  vesical  tumors  thorough  and 
certain,  and  seems  to  be  absolutely  devoid  of  danger. 

The  treatment  is  concluded  by  returning  the  patient  to  the  hori- 


TKKA'I'MKXT    OF    I'.I.A  I  )|  )KI;    TI.MOr.S  335 

zoiital  position,  llit'  iiistruiucnt  is  willidrawii,  tliu   bladder  is  waslied 
witli  warm  lioric  solution  and  a  rest  of  one  or  two  days  is  ordered, 

al(]i()u,i;li  this  is  not   a1)S()lutoly  necessary. 

Advantacks  of   Exdovesical   Treatment   of   Bladdfi;    Tr.Moits    W'liii 
LuYs'  Operating  Cystoscope 

1.  The  advantages  of  the  endovesical  method  over  the  suprapubic 
are  numerous.  First  of  all,  it  is  safe.  Not  only  is  the  operative  danger 
practically  nil,  but  better  still,  patients  do  not  have  to  undergo  the 
inconvenience  of  general  anesthesia,  nor  the  prolonged  stay  in  bed 
after  operation.  The  treatment  can  be  easily  applied  in  the  surgeon's 
office,  without  anesthesia,  and  the  patient  goes  home  after  the  treatment 
without  any  risk  of  danger;  he  also  continues  his  occupation  during  the 
entire  period  of  his  treatment.  For  tumors  of  the  bladder,  this  opera- 
tion is  similar  to  lilhotrity  in  vesical  calculi. 

Secondly,  it  is  highly  efficacious.  Speaking  of  the  endovesical  opera- 
tion, Weinrich  states  it  well  when  he  says,  "It  is  more  radical  than  the 
suprapubic."  This  is  an  incontestable  fact  although  it  looks  surpris- 
ing. It  is  well  known  that  papillomata  are  often  multiple  and  of  small 
size.  When  the  suprapubic  operation  is  performed,  a  papillomatous 
mass  of  fairly  large  size  can  be  easily  recognized ;  but  the  small  growths 
may  be  hard  to  distinguish,  because  they  hide  themselves  in  the  folds 
of  the  shriveled  mucosa,  so  that  the  most  careful  and  watchful  surgeon 
is  liable  to  close  the  bladder  without  having  touched  these  small  neo- 
plasms, which  will  eventually  develop  and  cause  recurrences.  With 
the  cystoscope  the  examining  eye  can  see  a  well-stretched  bladder  wall, 
and  no  vesical  tumor,  however  small,  can  escape  observation. 

Finally,  the  facility  with  Avhicli  the  endovesical  operation  can  be 
repeated,  makes  the  treatment  of  tumor  recurrences  quite  easy.  The 
frequency  of  these  recurrences,  especially  the  papillomata,  is  well 
known;  under  these  conditions  it  is  manifestly  impossible  to  jiropose  a 
repetition  of  suprai)ubic  section  at  very  short  intervals.  In  cancer  this 
fact  is  still  more  important  as  the  constant  recurrence  of  this  affection 
makes  the  endovesical  treatment  preferable. 

2.  The  advantages  of  my  direct  vision  cystoscojx'  over  Xitze's 
operative  cystoscope  and  the  instruments  similar  t<»  it,  in  the  treatment 
of  vesical  tumors,  are  the  following: 

It  is  very  easily  handled.  Witli  my  cNstoscopr  the  images  are 
direct  and  not  inverted,  so  tliat  tlie  sni-geon's  eye  does  nt)t  reijnire  spe- 
cial training  to  manipnlate  tlie  liand  and  the  cautei'v. 


PLATE  XXII 

Fig.  1. — Tumor  of  the  roof  of  the  Nadder  necl:;  tell- clap  per  appearance. 
This  tumor,  seen  with  the  direct  vision  cystoscope,  moved  forward  and 
backward  under  the  influence  of  respiration,  like  the  movement  of  a 
bell-clapper. 

Fig.  2. — Vesical  fistula  seen  after  a  perforation  of  the  bladder  by  an  ad- 
jacent abscess,  arising  from  a  suppurating  salpingitis;  the  abscess  had 
ruptured  into  the  bladder. 


Fig.  1. 


Fig.  2. 

PLATE  XXII 


TREATMENT    OF    BLADDER   TUMORS  337 

The  action  is  more  rapid  and  efficient.  With  Nitze's  instrument 
the  operation  is  performed  under  water  which  distends  the  bladder,  so 
that  the  platinum  wire  becomes  cooled  by  the  fluid  immediately,  and 
therefore  has  a  slower  and  less  complete  incandescence.  With  my 
cystoscope  on  the  other  hand,  the  operation  is  done  in  an  air  medium, 
and  it  can  be  readily  seen  that  the  cauterization  will  be  stronger  and 
more  efficacious  and  for  the  same  reason  the  duration  of  the  applica- 
tion will  naturally  be  much  briefer. 

Results  of  the  Endovesical  Treatment  of  Bladder  Tumors 

These  results  must  be  considered  separately  from  the  points  of 
view  of  curative  and  palliative  treatment.  In  benign  tumors  of  the 
bladder,  the  endovesical  method  must  be  considered  an  absolutely  and 
completely  radical  treatment.  With  this  method  the  papillomatous 
mass  can  be  fully  isolated  at  the  end  of  the  cystoscopic  tube  and  after 
a  certain  time  under  the  action  of  the  direct  cauterization,  nothing  is 
left  but  a  well-defined,  bloodless,  and  shining  scar  at  the  former  site  of 
the  raspberry-like  tumor.  Thus  it  can  be  said  truthfully  that  a  useful 
and  complete  surgical  task  has  been  accomplished. 

With  my  direct  vision  cystoscope  all  parts  of  the  bladder  are  easily 
accessible;  to  reach  the  fundus,  the  handle  of  the  instrument  is  ele- 
vated; for  the  right  wall,  the  handle  is  pushed  toward  the  left,  and 
for  the  left  wall,  to  the  right. 

In  cases  of  recurrent  papilloma  of  the  bladder  which  have  come 
under  my  observation,  the  recurrence  has  never  been  seen  at  the  site 
of  the  cauterization,  thus  proving  the  efficiency  of  this  method  of  treat- 
ment. In  a  case  reported  (Case  13)^  the  complete  success  resulting 
from  this  treatment  was  verified  by  cystoscopy  performed  three  times 
by  a  colleague;  there  was  no  recurrence.  In  another  case  (Case  3) 
complete  success  was  not  obtained  because  the  papillomata  rei3roduced 
themselves  in  the  form  of  seeds  all  over  the  bladder,  but  recurrence 
never  appeared  at  the  spots  that  had  been  cauterized.  This  case  is 
still  more  interesting  because  the  recurrence  took  place  after  a  supra- 
pubic section.  In  Case  9,  direct  cauterization  immediately  and  com- 
pletely stopped  the  very  copious  hemorrhages;  these  did  not  return 
for  two  years  afterward.  In  Cases  12  and  14,  the  patients  unfor- 
tunately could  not  be  traced;  but  the  direct  cautery  immediately 
stopped  the  bleeding  in  these  cases. 

The  following  histories  of  cases  are  particularly  instructive,  be- 
cause they  show  the  undeniable  necessity  and  efficiency  of  the  endovesi- 
cal treatment: 


338 


CYSTOSCOPY   AND    UEETHROSCOPY 


Case  1. — Recurrent  Fapillomata  of  the  Bladder  Treated  iy  the  Endovesical  Method. 
M.  S.,  male,  aged  forty-nine  years,  referred  to  me  July  21,  1904,  by  my  professor,  Broca. 
The  patient  complained  of  considerable  hematuria,  paleness  and  generally  weakened  condi- 
tion. This  hematuria  had  occurred  four  times  in  one  year ;  each  time  it  haa  lasted  from 
two  to  six  days,  stopping  sj)ontaneously  after  rest  and  milk  diet.  The  hematuria  for  which 
he  decided  to  have  a  consultation,  had  lasted  four  days.  I  first  examined  the  bladder  with 
the    ordinary   indirect    cystoscope   and    discovered   the   presence   of    a    small    tumor,    the    size 


4  ^f^^^^A^S/r/. 


Fig.   201. — Vesical    papilloma;    microscopic    section. 

of  a  large  strawberry  situated  at  the  bladder  fundus  near  the  right  ureteral  orifice  and  slightly 
overlapping  it.     The  rest  of  the  bladder  was  perfectly  normal. 

In  view  of  the  lesion  being  so  limited,  the  suprapubic  operation  was  decided  upon. 
It  w^as  performed  on  July  26  by  Broca,  with  my  assistance.  The  extracted  tumor  was 
examined  histologically  at  the  faculty's  laboratory  of  pathologic  anatomy,  by  Decloux. 
The  accompanying  illustration  (Fig.  201)  which  is  an  exact  reproduction  of  a  section  of 
the  tumor,  shows   a  typical  paj)illoma. 

The    subsequent    operative    procedures    were    very    simple.      The    bladder    was    quickly 


TItKATMKXT    OF    l;L.\l)IiKi;    TUMOKS  339 

cliisril,  llic  mini'  licc;iiiir  ]  ici' feci  1  y  clciir,  Jilid  lllr  |i;ilii'iit  <|llil  tlic  ll(is|iil  .'i  I  slinrlly  :i  t't('r\v;i  nl, 
;i  |i|i:i  rciil  \\    iMi  icil. 

lie  rcnijiiiKMl  in  lliis  s:il  isfactoiy  (•(niditioii  witli  clear  urine  aii<l  perfect  <ieiieial  lieallli, 
exactly  mic  yrai.  On  July  '2'2,  l!)()a,  lie  ict  iirtie<l,  cdiiiplaiiiiiig  of  slifflitiy  liioixly  urine,  for 
three  wei'ks  jmst.  l-^xaminnt  inn  with  the  (Jiilinaiy  imlirect  cvstoscope  rcvcaleil  the  presence 
of  three  snnill  pa  |iilh)inal  cms  linilics  iIm'  si/.c  (if  small  st  lawliei'ries,  situated  r)n  the  rit;ht  wall 
of  the  liladdei.  A I  the  site  nl'  llie  oiiiiihal  tunnM-  a  distinct  white  scar  was  seen;  there  was 
no  recurrence  at  that  ]Miint.  The  heniatinia  liein;^  sli};ht,  tiie  patient  I'cfused  treatnu'ut, 
remaining  with  the  slight  lihcdin;;  till  Octidjci,  l!i(i5.  At  that  time,  on  the  advice  of  liroca, 
lie  asked  me  to  treat  him  locally  thiough  the   natural  passage. 

The  first  application  with  my  direct  vision  eystoscope  was  maile  Octoher  '27.  'I'iie  small 
|ia|iilliiniata  were  clearly  disf  inguisheil  ;  Hie  fringes  of  each  little  tumor  ha<l  the  form  of 
halls  of  twine.  Oii(>  of  these  masses  was  isolated,  lirought  to  the  opening  of  the  cystoscopic 
tube  and  luiiiicd  with  the  galvanocautery.  The  point  of  the  cautery  that  1  iiseil  at  that  time 
was  very  thin  and  narrow  and  did  not  allow  much  cauterization.  At  this  first  operation,  tlie 
patient  suffered  no  pain  whatever;  the  second  day  he  went  about  his  usual  occui)ation.  On 
the  following  days  he  noticed  that  small  pieces  of  burned  tumor  weic  being  eliminated  with 
his  urine;  he  brought  some  of  the  pieces  to  me. 

On  November  6,  at  a  second  application  of  multiple  cauterization,  a  few  detached 
pieces  were  extracted  with  a  special  toothed  forceps,  this  being  followf^l  by  a  slight  hemor- 
rhage which  was  soon  under  control.  Copious  vesical  irrigations  with  a  warm  boric  solution 
and  antipyrin,  completely  stopped  the  oozing  of  blood  and  the  patient  went  home  without 
ditSculty.  For  two  days  subsequently  the  patient  had  some  hematuria,  which  kept  him  in 
his  bed.  Blood  clots  formed  in  the  bladder,  which  were  aspirated  through  a  large  metallic 
tube.     Soon  the  hematuria  stopped  completely,  the  urine  became  clear  and  remained  so. 

It  is  worth  noting  that  the  postoperative  hematuria  was  undoubtedly  due  to  tlie  trac- 
tion of  the  forceps  and  not  to  the  galvanocautery.  Since  that  time,  I  have  aliandoned  the 
use  of  the  forceps  completely.  A  third  examination  showed  only  two  jjapillomata  left ; 
they  were  also  destroyed  by  the  cautery. 

The  patient  remained  in  excellent  condition  with  clear  urine  and  no  tiace  of  lilood 
for  many  months.  In  February,  190G,  desiring  to  verify  his  condition,  although  in  good 
health,  I  examined  his  bladder  with  the  indirect  eystoscope,  and  found  a  new  croj)  of  small 
pjapillomata.  These  did  not  recur  in  the  cauterized  places,  but  were  spread  about  like  seeds 
in  various  parts  of  the  bladder.  Some  were  like  a  pin  head,  others  a  little  largei  like  grains 
of  hemp  seed ;  the  latter  were  situated  on  the  superior  part  of  the  bladder  neck,  adjacent  to 
the  base  of  the  prostate.     They  were  burned  with  an  improved  model  galvanocautery. 

The  cauterization  of  these  paj^illomata  situated  on  the  superior  aspect  of  the  bladder 
neck  was  facilitated  by  instructing  the  patient  to  make  pressure  on  the  upper  bladder  wall 
with  his  hand;  thus  the  tumors  were  pushed  into  the  cystoscopic  tube,  making  their  destruc- 
tion extremely  simple.  To  determine  the  result  obtained  after  burning,  the  iiatient  rehixes 
the  vesical  wall  and  the  scars  are  examined  in  profile. 

The  patient  remained  in  perfect  health  with  clear  urine  for  more  tlian  live  months. 
In  November,  1906,  he  came  back  for  examination  although  he  was  without  any  mor1>id 
symptom.  I  found  another  proliferation  in  sjiots  not  treated  liefore.  These  also  were 
cauterized  in  the  same  way.  In  Februar.y,  3907,  still  another  examination  was  made,  with 
additional  cauterization  of  new  growths.  The  general  and  local  conditions  continue  satis- 
factory.    I  see  the  patient  regularly  once  a  year. 

In  point  of  fact,  the  patient  has  not  seen  any  further  blood  in  his  urine  since  the 
endovesical.  treatment  was  begun,  a  period  of  more  than  ten  years,  in  spite  of  continuous 
recurrences  of  the  papillomata  in  various  spots.  This  is  due  to  the  fact  that  the  endovesical 
treatment  prevented  the  development  of  the  papillomata  and  their  sul)sequent  hemorrhages. 
Finally,  a  detail  which  might  be  interesting  in  a  general  way;  in  August,  1907,  this  patient's 
daughter  consulted  me  for  a  small  papillonm  of  the  face,  which  I  burned  at  once  witli  the 
galvanocautery. 


340  CYSTOSCOPY    AND    URETHROSCOPY 

Case  2. — Tumor  of  the  Bladder  Treated  Endovesically.  Mrs.  M.,  aged  sixty-five  years,  . 
referred  to  me  by  Broca,  in  May,  1907,  for  severe  hematuria.  The  patient  li|i^d  slight  bleed- 
ing attacks  for  three  years.  She  decided  to  seek  medical  advice  because  her  health  was 
being  jeopardized.  When  I  first  saw  her,  the  urine  was  extremely  bloody,  so  that  indirect 
cystoscopy  was  impossible.  In  spite  of  repeated  irrigations  and  washings,  a  distinct  view 
could  not  be  obtained.  On  the  other  hand,  using  my  direct  vision  cystoscope,  I  immediately 
found  a  tumor  the  size  of  a  walnut,  parts  of  which  were  necrotic.  It  was  situated  in  the 
median  line  of  the  bladder  fundus,  stretching  toward  the  left  lateral  wall.  The  right  lateral 
wall  was  perfectly  noimal.  I  cauterized  the  tumor  in  three  different  sittings,  with  truly 
remarkable  results.  The  hematuria  stopped  completely,  the  urine  became  absolutely  clear, 
and  the  frequency  in  urination,  which  before  my  intervention  was  hourly  by  day  and 
every  two  hours  at  night,  was  perceptibly  ameliorated.  Subsequent  to  June  7,  she  urinated 
only  every  three  hours  during  the  day,  and  not  at  all  during  the  night.  The  vesical  capacity 
at  the  beginning  only  80  c.c.  was  increased  to  200  c.c. 

Finally,  the  general  condition  which  was  almost  cachetic,  improved  rajsidly,  and  the 
patient  was  enabled  to  attend  to  her  usual  duties  without  undue  fatigue.  I  saw  her  again 
in  September,  1907,  and  found  that  she  was  maintaining  her  excellent  health.  Cystoscopy  at 
that  time  revealed  a  small  recurrent  tumor  the  size  of  a  pea  situated  at  the  site  of  the 
former  growth.     This  was  immediately  cauterized  with  the   galvanocautery. 

As  in  the  former  case,  I  advised  the  patient  to  come  for  examination  every  six  months, 
so  as  to  prevent  possible  hemorrhages  caused  by  proliferations  of  the  tumor. 

Case  3. — Tumor  of  the  Bladder  Treated  hy  Galvanocautery  thro^igh  the  Direct  Vision 
Cystoscope.  Mrs.  S.,  aged  sixty-eight  years,  referred  by  Stora,  October  19,  1910.  She  com- 
l^lained  of  passing  dark  and  bloody  urine  occasionally,  sometimes  of  a  blackish  color.  Cystos- 
copy showed  a  normal  bladder,  l^ut  behind  the  left  ureteral  orifice  a  raspberrj'-like  tumor  the 
size  of  a  cherry  was  revealed,  which  was  evidently  a  papilloma.  All  trace  of  this  growth 
disappeared  completely  after  three  cauterizations  through  my  direct  vision  cystoscope. 

Case  4. — Papilloma  of  the  Bladder  Treated  hy  Galvanocautery  Through  the  Direct  Vision 
Cystoscope.  Mrs.  C,  aged  twenty-seven  years,  referred  to  the  genito-urinary  clinic  of  Ba-oca 
Hospital,  by  Eobineau,  March  8,  1912.  The  patient  complained  of"  intermittent  attacks  of 
pain  in  the  left  kidney  region;  her  left  kidney  was  lower  than  normal  and  the -urine  was 
cloudy.  Eobineau  thought  of  a  left  pyonephrosis,  and  wanted  me  to  make  an  examination  of 
the  separate  urines  of  both  kidneys.  When  I  cystoscoped  her,  on  March  S,  I  was  greatly 
surprised  to  find  a  tumor  of  the  bladder  with  the  typical  aspect  of  a  ijapilloma  situated 
near  the  left  ureteral  orifice.  It  is  highly  probable  that  this  villous  tumor  was  pressing  upon 
the  left  ureteral  orifice  so  that  it  caused  a  difficulty  in  the  evacuation  of  the  left  ureter  and 
kidney,  and  to  a  certain  extent  caused  the  pains  in  the  left  kidney. 

I  cauterized  the  tumor  with  my  cystoscope  three  times ;  i.  e.,  on  March  15,  23,  and  30. 
The  growth  disappeared  entirely  after  this  intervention.  This  tumor  is  well  illustrated  as 
it  appeared  when  first  examined  on  March  8,  in  Plate  IX,  Fig.  4.  In  Plate  IX,  Fig.  2, 
the  same  tumor  is   shown  as  it   appeared   after   the   first  cauterization. 

I  saw  this  patient  again  a  year  later,  that  is.  May  30,  1913.  At  that  time,  she  com- 
plained of  cloudy  urine  and  was  anxious  to  know  whether  the  vesical  tumor  had  recurred. 
The  examination  showed  that  she  was  suffering  from  a  gonorrhea  which  she  had  contracted 
from  her  husband.  The  external  orifice  of  the  urethra  was  extremely  edematous;  the  cloudy 
urine  was  due  to  a  purulent  urethral  discharge,  the  fundus  of  the  bladder  was  inflamed ; 
besides,  she  had  a  severe  bartholinitis.  Antigonorrheal  treatment  was  instituted  and  after 
the  acute  stage  had  passed,  I  examined  her  (June  6),  but  did  not  find  any  trace  of  the 
vesical  tumor.  Another  cystoscopic  examination  in  February,  1914  (two  years  after  the 
first  treatment)   showed  no  trace  of  any  lesion. 

Case  5. — Tumor  of  the  Superior  TT'all  of  the  Bladder  Nech  Treated  With  the  Direct 
Vision  Cystoscope.  Mrs.  B.,  aged  forty-one  years,  was  seen  on  June  13,  1913,  at  the  urinary 
clinic  of  Broca  Hospital.     She  complained  of  cloudy  urine  and  frequency  of  urination  both 


Tl'vKAT.MKXT    OF    ISLADDKU    TI'.MOKS  341 

by  day  and  iiiglit.  On  oxaininnt  imi  llir  hlidilcr  capacity  was  found  reduced  to  aljout  100 
('.('.  TIh'  urctluii  was  small  ami  lilnnus  ami  tliis  made  tlic  passaj^e  of  the  cystoscope  quite 
ilit1i.-iill. 

However,  llic  instrument  was  introduced  and  it  was  found  that  she  had  a  severe  gen- 
eralized cystitis.  But  -while  the  cystoscopic  tube  was  being  withdrawn,  a  tumor  was  seen 
immediately  behind  the  neck,  hanging  from  the  superior  wall  and  acting  like  a  valve  to  the 
extremity  of  the  tube.  The  growOi  disappeared  completely  after  two  apjdications  of  the 
galvanocaufcry.     The  lumor  is  well  illustrated  in  Plate  XXII,  Fig.  1. 

Subsequently  she  was  treated  with  renal  lavage  for  a  loft  pyonephrosis.  I  examined 
her  again  seven  months  later  and  found  no  trace  of  the  tumor.  The  report  of  these  cases 
shows  conclusively  the  value  of  galvanocauterizatioii  with  my  direct  vision  cystoscope. 

The  following  case  of  vesical  tumor  destroyed  through  the  natural 
passages-  was  reported  by  Caspari,  of  Lausanne: 

' '  I  would  like  to  call  attention  to  a  very  simple  instrument  tliat  I  have  found  very  use- 
ful; i.e.,  Luys'  Direct  Vision  Cystoscope.  I  have  used  it  with  considerable  success  in  the 
following  case : 

"Mrs.  M.,  aged  forty-six  years.  Menstruation  ceased  in  September,  1905.  On  the 
morning  of  August  10,  she  became  frightened  at  the  appearance  of  a  large  quantity  of 
blood  in  the  urine.  She  had  ' '  lost  her  blood, ' '  as  she  termed  it,  two  years  previously.  An 
eminent  gynecologist  was  consulted  but  could  not  determine  the  source  of  the  hemorrhage, 
as.it  had  ceased  when  she  came  to  hini  for  advice.  An  'exploratory'  curettage  was  pro- 
posed, but  not  accepted.  In  the  present  instance  the  blood  came  during  micturition.  Nothing 
abnormal  was  found  in  the  genital  tract.  I  cystoscoped  the  patient  in  the  afternoon  of  the 
same  day,  using  the  indirect  cystoscope.  There  was  no  hemorrhage  at  that  time,  the  urine 
being  perfectly  clear.  I  immediately  found  a  papillomatous  tumor  on  the  left  lateral  side  of 
the  bladder  fundus. 

"It  began  at  the  left  ureteral  orifice,  which  was  obscured  by  a  few  villi,  and  extended 
thence  outward  and  backward  nearly  four  centimeters  from  this  orifice.  It  was  as  large  as 
two  big  superimposed  raspberries.  It  was  shaped  like  a  mushroom  the  cap  of  which  was 
oval  and  its  surface  uneven  with  well-marked  villosities  floating  in  the  fluid  like  the  arms 
of  an  octopus.  The  pedicle  of  the  tumor,  hidden  behind  the  mass,  was  rather  imagined  than 
actually  seen.  It  was,  in  fact,  elongated  from  within  outward  and  anteroposteriorly ;  the 
mass  was  oval  like  the  surface  but  its  dimensions  wore  much  smaller.  Tlie  rest  of  the  bladder 
was  normal.  I  photographed  the  neoplasm  with  the  photographic  cystoscope,  but  the  result- 
ing picture  was  unfit  for  reproduction. 

"The  tumor  being  well  localized  and  isolated,  and  undoubtedly  papillomatous  and 
benign,  I  decided  to  destroy  it  with  Luys'  cystoscope  through  the  natural  passages.  The 
result  was  complete  and  perfect  after  three  applications  at  various  intervals.  Tlie  patient 
was  cured  without  any  complications  whatever.  She  did  not  stay  in  the  hospital,  but  attended 
to  her  usual  occupation  and  enjoyed  all  the  pleasures  to  which  she  was  accustomed.  Eighteen 
days  after  the  second  cauterization,  I  made  a  control  cystoscopic  examination  with  the  indirect 
cystoscope.     The   following  was  noted : 

"The  tumor  has  disappeared  completely,  except  a  small  round  granulation  situated  at 
the  external  extremity  of  the  surface  occupied  formerly  by  the  tumor.  Tliis  region  itself 
can  hardly  be  distinguished  from  tlio  rest  of  the  vesical  mucosa;  there  is  a  very  slight  cicatri- 
cial appearance  in  the  form  of  a  line  corresponding  to  the  original  insertion  of  the  neoplasm. 
This  line,  staiting  from  the  ureteral  orifice  extends  outward  and  slightly  backward  up  to 
the  above  mentioned  granulation.     As  a  precaution  I  cauterized  this  granulation  also. 

"Cystoscopic  examination,  a  week  later,  showed  tliat  the  tumor  did  not  exist  any 
longer;  the  original  site  was  represented  only  liy  a  darker  cnloratiiui  of  the  mucosa.  The 
technic  employed  was  the  one  described  by  Luys. ' ' 


342  CYSTOSCOPY    AXD    URETHEOSCOPY 

[The  editor  has  assumed  the  responsibility  of  omitting  the  rest  of 
this  report,  inasmuch  as  it  is  an  exact  repetition  of  the  antl^or's  discus- 
sion on  the  technic  advocated  by  him  in  the  treatment  of  vesical  tumors. 
Caspar! 's  conclusion  follows. — Editoe.] 

' '  The  endovesical  method  seems  to  be  the  method  of  choice  when  we  have  to  deal  with 
benign  tumors  of  the  bladder,  of  small  size  and  not  very  numerous ;  also  for  the  frequent 
recurrences  of  these  tumors.  In  the  female,  Luys'  method  must  certainly  be  given  prefei'- 
ence  because  of  the  excellent  results  obtained.  I  am  happy  to  be  able  to  assist  in  making  it 
better  known,  having  been  the  first  to  cure  a  case  in  Switzerland  with. this  method." 

In  addition  to  these  very  characteristic  histories,  we  may  cite  also 
the  interesting  work  upon  the  same  subject  by  Tixier  and  Gauthier,  of 
Lyons. ^  There  are  also  two  interesting  reports  by  de  Keersmaecker,  of 
Antwerp,*  on  the  extirpation  of  bladder  polyi^i  through  the  cystoscope. 

CoisTTEAIXDICATIOXS   TO    THE    El^DOVESICAL   TrEATMEiSTT   OF   BlADDER 

Tumors 

If  endovesical  cauterization  is  the  method  of  choice  for  all  small 
tumors  of  the  bladder,  and  especially  j)apillomata,  I  must  say  it  can 
not  be  considered  a  radical  treatment  in  the  large  and  malignant  tumors 
with  wide  and  infiltrated  bases;  also  in  obe.^e  patients  in  whom  the  dis- 
tention of  the  l)ladder  can  not  be  obtained  on  account  of  the  consider- 
able abdominal  iDlethora.  In  these  cases,  Nitze's  operating  cystoscope 
should  be  used. 

In  conclusion,  the  endovesical  treatment  of  bladder  tumors  with  my 
direct  vision  cystoscope  is  to  be  recommended,  for  its  remarkable  effici- 
ency and  benign  character."'  Up  to  the  j)resent  time,  I  have  made  over 
fifty  applications  of  this  method  in  men  and  women,  in  some  cases  often 
repeated,  without  a  single  untoward  incident. 

REFEEEi^CES 

iLuys:     2d  Congress,  German  Urological  Society,  Berlin,  1909,  p.  435. 

-Communication  to  the  Vaudoise  Medical  Society,  meeting  of  Dec.  4,  1909,  also  La  Clinique, 

1910,  p.  25. 
sTixier  and  Gauthier:     Societe  des  Sciences  medicales,  June,  1911. 
4De  Keersmaecker:      Societe  beige   d'Urologie,   June,  1905. 
■■iCaspari:     Traitement  des  tumeurs  de  la  vessie.  La  Clinique,  1910,  p.  25. 

Treatmex^t  of  Bladdee  Tumoes  AVith  the  Cold  oe  Hot  Sx^aee 

This  method  of  treatment  A\as  employed  by  Xitze,  as  ^^I'^viously 
stated;  but  he  used  this  method  only  as  a  preliminary  step  in  the  gal- 
vanocauterization  of  bladder  tumors;  he  snared  the  tumor  first  and 
then  he  cauterized  the  pedicle. 

The  method  of  Blum,  of  Vienna,'  is  entirely  different.    This  author 


TIM'.A'r.MKXT    Ol'    l',I,.\l)IiKi;    TCMOllS 


lias  |)iil)li.-li(M|  a  sci'ics  (tf  iiilci'csliiii;-  n'|)()its  on  lii>  iiidliod,  wliidi  lia> 
i^'ivcii  splendid  icsuHs.''  Xilzc's  Insi  rnniciii  consislfMl  cssciilially  of  a 
)'i,<;'i(l  syslcin,  w  liidi  dillVi-s  coinplctcix-  from  llic  llcxihlf  system  |»i-()- 
])()se(l    l»y    I5lnni. 

()tliei-  anlliors,  pi'eccdini;  lilnni.  liki-  Schlauinl  wcil,  l-'faidc.  and 
Boliine,''  had  coiiceixcd  llie  idea  of  n^ini;-  IIm'  eat  iielerizin;;'  eysloseojx* 
as  an  ojx'i'atini;'  in>t  iiinient.  hut  IJhini  w  a>  the  lirst  to  (h'\'ise  a  ])i'a('- 
tical  a])])ai'atus,  whiieh  thn>oj)ene(|  a  new  patii\\a\-  lo  endoNcsical  opera- 
tions. 

I'hini's  instiunient  can  he  inti-odueed  into  the  eatheteri/.iiii;-  cyslo- 
s('0])e  in  the  same  way  as  a  ureteral  eatiieter.  To  ])oiiit  the  snare  to- 
ward (lilTei-eiit  poi-tions  of  iIk^  l)ladder,  lie  utilizo  Alharran's  defleetor. 
The  essential  element  of  liliiin's  instrument  is  a.  snare  eiivelo])ed  hy  a 


Fig.   202. — Eliini's   operating   cystoscope. 

Ilexihle  ]netallie  slieet,  which  ean  he  inti'odueed  in  its  entirety  into  tlu' 
eliaimel  proxided  foi-  the  ur(-teral  catheter  in  the  catheteri/ini;'  cysto- 
scope. 

Blum's  opei-ating  instrument  (Fi.u'.  202)  is  composed  ot"  a  steel 
sprino- 1.8  mm.  wide,  correspond in.-^-  in  caiiher  to  a  Xo.  G  Cliarriere.  This 
is  the  condnctini;-  channel  For  all  the  instruments.  This  s])rin,u'  of  steel, 
very  Ilexihle  and  free,  lias  a  solid,  strai<;ht  end  that  is  stroiiii'  enon.u'li 
to  resist  i)ressnr(»  u])on  aii>-  part  of  the  vesical  nmcosa,  as  for  instance, 
the  base  of  the  tumor.  The  sprini.;-  1ias  an  eye  at  its  vesical  end,  to 
Avliicli  a  bronze  aluminum  wii-e  is  attached:  the  other  extremity  is  at- 
tached to  the  end  of  the  ohtui-atoi'  which  can  ht'  inserted  or  withdrawn 
within  the  himeii  of  the  spiral  in  ordei'  to  enlarge  or  diiiiinish  the  snare. 


PLATE    XXIII 

Fig.  1. — Edematous  aspect  of  a  ibreteral  orifice;  undoubtedly  indicating  a 
diseased  condition  of  the  ureter  or  of  the  corresponding  kidney. 

Fig.  2.-^Edevia  of  the  ureteral  orifi,ce  observed  iii  connection  with  a  ureteral 
calculus. 


Fig.  1. 


Fig.  2. 

PLATE  XXIII 


TREATMENT    OV    Br.ADDKn    TTMOHS  34.") 

The  calilx'f  of  Uic  cxtcnial  cxti'diiilx  ol'  the  spi-iiii;-  is  siifliciciit  to 
allow  the  stool  ohturaloi-  to  coniplctcly  close  its  liiiiicii.  Tlic  iiitcnial 
extremity  lias  a  semilunar  grooxc  in  wliicli  ilic  snni-c  is  fully  lodgcMl 
Avlieu  reduced  to  its  minimum  size. 

The  niaiii|tula1i()n  of  lliis  inslnniiciil  is  racililalcd  lt>"  llic  use  ol" 
LeiterV  diuiii  linndlc;  lliis  lias  a  llai  sju'inx,  oNcr  tlie  external  exti'ein- 
ity  of  Avliicli  the  obturator  is  rolled.  The  i)lain  snai-e  can  be  replaced  by 
a  forceps  wliicli  is  operated  by  llie  ol)turator  and  the  di'um  handle. 
Zuckerkandh  of  A'icnna,  lias  devised  a  special  caulcM-y  which  can  be 
attached  to  this  instruinent;  it  aids  ii!  Ihc  caidcri/alion  of  the  base  oi* 
the  tumors. 

Preparation  of  the  Patient. — Blum  anesthetizes  the  anterior  and 
posterior  portions  of  the  nrethra  wi-tli  three  or  fonr  c.c.  of  a  5  per  cent 
solution  of  novocaine.  Sometimes  in  sensitive  patients  he  injects  liypo- 
dermatically  two  c.c.  of  morphine,  or  he  "-ives  the  patient  an  antipyrin 
irrigation.  After  the  bladder  is  emptied,  he  instills  five  c.c.  of  a  1 :1000 
solution  of  adrenalin,  to  prevent  bleeding-.  (This  dose  of  adrenalin 
seems  quite  strong  and  dangerous.)  Finally,  to  obtain  the  clearest  pos- 
sible vision,  the  bladder  is  filled  with  250  to  300  c.c.  of  sterile  water. 

The  quantity  of  water  to  be  injected  varies  according  to  the  indi- 
vidual. Blum  has  noticed  that  in  tumors  on  the  roof  of  the  bladder 
or  on  the  anterior  wall,  it  is  advisable  to  inject  a  smaller  cpiantity  of 
water,  so  as  to  bring  the  cystoscope  to  a  more  convenient  distance. 
Thus  in  a  man  eighty  years  old,  with  a  pai^illoma  on  the  roof  of  the 
bladder,  he  employed  the  following  jirocedure:  With  150  c.c.  of  water 
in  the  bladder,  the  tumor  Avas  so  far  away  that  he  could  not  grasp  it 
with  the  snare.  He  then  opened  the  snare  so  widely  that  the  largest 
circumference  of  the  tumor  could  easily  be  enclosed  by  it.  Then  he 
gradually  emptied  the  bladder  till  thirty  or  forty  c.c.  remained.  In 
this  Avay,  the  vesical  tumor  descended  spontaneously  into  the  snare 
and  was  thus  extirpated. 

Preparation  of  the  Instrument. — The  operating  instruments  are 
attached  to  Xitze's  catlieterizing  cystoscope.  The  bronze  aluminum 
wire  constituting  the  snare  is  pulled  so  that  it  assumes  the  sha]ie  of 
the  letter  U,  one  centimeter  in  length;  this  is  completely  hidden  in  the 
concavity  of  Albarran's  deflector.  The  iiislrunieid  is  i-.ow  introduced 
into  the  bladder. 

Operating'  Technic. — AVhen  the  tumor  ai^i^ears  in  the  visual  Held, 
the  spiral  spring  is  ijushed  inward  until  its  extremity  is  seen:  then  the 
loop  is  formed  in  a  circle,  the  diameter  of  which  sluudd  be  a  little 
larger  than  the  greatest  circumference  of  the  tumor.  The  s])iing  is  so 
manipulated  that  the  loop  is  perpendicular  to  the  length  of  the  tumor. 


346  CYSTOSCOPY    A2^D    URETHROSCOPY 

With  the  aid  of  Albarran's  deflector,  the  Ioo^d  is  brought  around  tlie 
tumor  and  the  spring  is  pushed  to^^'a^d  the  vesical  wall  so  that  it 
presses  upon  the  normal  vesical  mucosa. 

When  tlie  looj)  is  at  the  base  of  the  g^o^vth,  the  ol)turator  is  jDulled 
forcibly.  During  this  maneuver  a  sensation  of  crackling  of  the  de- 
stroyed tissues  is  often  felt.  It  is  important  to  make  sure  that  the 
loop  is  firmly  attached  to  the  pedicle,  for  then  the  tumor  will  follow 
all  the  movements  of  the  sx)iral. 

After  fixation  is  tlius  secured,  the  cystoscope  is  withdrawn  leaving 
the  spiral  and  the  snare  in  the  same  manner  that  a  ureteral  catheter  is 
left  in  the  ureter.  The  snare  is  left  in  this  position  for  24,  36,  or  48 
hours,  when  it  usually  comes  out  spontaneously.  Sliortly  thereafter  the 
patient  generally  passes  the  entire  tumor  with  the  first  micturition. 

It  is  well  not  to  cystoscope  the  patient  for  eight  to  fourteen  da^^s 
after  this  operation,  on  account  of  possible  hemorrhages.  But  if  it  is 
done,  an  ulceration  will  l)e  seen  at  the  site  of  the  former  growth,  in  the 
form  of  a  crescent  covered  by  necrotic  tissue.  Fifteen  days  after  opera- 
tion the  eschar  usually  comes  out  spontaneously,  accompanied  by  a 
slight  hemorrhage.  In  this  way,  the  destruction  of  the  tumor  is  at- 
tained at  one  sitting  without  the  loss  of  a  drop  of  blood.  This  is  cer- 
tainly an  ideal  technic  for  a  simple  operation ;  but  often  certain  difficul- 
ties are  encountered. 

The  operative  difficulties,  are  the  following:  First  the  tumor  can 
not  be  grasped  as  above  described.  In  this  case  the  double  catheter- 
izing  cystoscope  should  be  used.  The  spiral  and  snare  are  passed  into 
one  of  the  channels,  and  a  toothed-forceps  into  the  other.  The  forceps 
grasps  the  tumor  and  the  snare  is  worked  around  the  growth  as  close 
to  the  base  as  is  possible. 

Other  difficulties  are  due  to  the  indirect  cystoscope  itself,  the 
principal  being  that  the  vesical  fluid  becomes  cloudy.  Finally,  serious 
hemorrhages  are  always  to  be  feared,  particularly  when  the  eschar 
separates  and  comes  avray. 

Operative  Results. — Blum  has  operated  on  44  bladder  tumors  of 
which  37  were  papillomata.  In  one  case  he  was  compelled  to  resort 
to  suprapubic  cystotomy  because  of  a  A^ery  dangerous  hemorrhage 
which  followed  the  seiDaration  of  the  eschar.  (This  occurred  eight  or 
fifteen  days  after  the  endovesical  operation,  while  the  operator  was 
cystoscoping  the  patient  in  order  to  verify  the  result.)  In  all  the 
ether  cases  the  endovesical  operation  was  successful.  Two  cases 
recurred  and  were  again  operated  on  in  the  same  way.  Blum  prefers 
the  cold  snare  because  the  hot  snare  might  burn  and  perforate  the  blad- 
der wall. 


TKKA'I'MK.Vr    (H-     l!L.\l»l>Ki;    'IIMdltS  o47 

]:i:ri-:i;i;x('K.s 

ir.liini.   X'ictur:      I'lin   iiciii's  iiit  lavcsikali's  ()|n'inl  iohs  vrrfidm'ii.  Ztsi-lic.   f.    rrol..    I'.in'.i,   iji,   ll(i. 

-Illiini:      /tsrhr.    f.    I'lnl..    I'.H  1.    p.    Sl'A. 

-liuliiiic.  I>'iil/.:     Ziir  'rnliiiil^  dcr  iiil  r:tv('sik;ilcii  Opi'iat  inn  \(iii   liUi.-iciil  ui.Kircii,  Zts<-lir.  f.   Urol., 

I'.MI!>.    iii.    .".III. 

P]lecti;()('().\(;ii..\i'I().\  ok  Ti'.moks  ok  tiik   Iji.addku 

'^^riic  li'caliiM'iit  of  hiaddcr  tiiinors  by  clccl  KO('oa,i;iilalioii  lia.<  Ix'cii 
iilili/cd  ))ecaiiso  of  llic  splciidi:!  it'sull.<  oMaiiKMl  with  this  inetlio«l  in 
luiiiors  on  aooossihlc  jjaits  oT  llic  hody,  liy  DoycMi'  in  France,  Bei'iidt, 
ill  Ansti"ia,  and  Xa.iiolselmiidt-'  in  GerniaiiN'.  Doyen''  first  makes  a  supra- 
|iiil)i(*  incision  and  llirou^li  lliis  opciiiiii;'  in  tlic  bladder  lie  apjilics  clc;-- 
troeoa,i>,nlation  to  the  tumor. 

Edwin  Beer*  of  Xew  York,  in  11)10,  eoneeived  tlie  idea  of  applyitift' 
electrof'oa,i;ulation  to  bladder  tuiiiois  llirouft-li  tlie  natural  eliannels. 
lie  nscd  tlic  indirect  cystoscojx'.  A  number  of  Americans  shortly  after- 
ward ])ublished  eases  confirming'  the  value  of  this  method. 

Among  the  most  noted  publications  may  he  mentioned  those  of 
Buerger  and  Wolharst,'  Gardner,''  Sinclair,'  McCartliy,-  Judd,''  Harps- 
ter,'"  Binney,^^  AVatson,'-  Pitcher,^'  and  Barney."  Reports  have  also 
l)een  pul)lished  hy  Bachrach,^''  in  Austria,  Kuttner,^''  Bucky  and 
Frank, ^'  in  Germany,  and  in  France  by  Legueu,'^  Jfeitz-Boyer  and  Cot- 
tenot,"  Andre-°  and  Lepoutre  and  d'Halluin.-^ 

Electrocoagulation  is  produced  by  high-freqnency  currents  of  loir 
tension;  while  the  spark  produced  by  the  high-frerjuency  current  and 
Itif/li  tension  Avhich  constitutes  "fulguration,"  exerts  but  a  supei-ficial 
action,  and  no  effect  deeper  than  three  or  four  luni.  Doyen  has  deiiion- 
strated  that  with  the  high-frequency  spark  and  low  tension,  electro- 
coagulation can  be  ol)tained  in  the  substance  of  the  tissues  to  a  depth 
of  fifteen  to  twenty  mm. 

The  cni'rent  nec(^ssary  for  electrocoagulation  is  secured  through 
a  special  current  transfoi'mer  (Fig.  203).  'This  a])])aratus  is  com])osed 
of  a  transformer  Avhich  changers  the  street  current  with  its  high  voltage 
running  up  to  se\-eial  luillioii  volts.  Tliis  cui-rent  ]tasses  into  Oudin's 
i-esonator;  a  tliird  part  I'egnlates  tlie  intensity  of  the  cnri-ent. 

Si^arking  is  not  absolutely  essential  lor  electi-ocoagulation.  Tf 
instead  of  lea\ing  a  ga})  between  the  elect I'ode  and  the  tumor,  tlie  two 
are  brought  into  direct  contact,  coagulation  will  be  ])ro(luced  without 
carbonization,  because  its  action  is  not  due  to  the  heat  alone. 

When  the  electric  current  is  not  very  strong,  and  it  is  used  with 
very  large  electrodes  having  (Mjual  surfaces,  "diatliei-mia"  oi'  "theiino- 
lienetration"   is  ])roduced;  this  sini])ly   produces  a  sensation   of  heat. 


348 


CYSTOSCOPY    AND    URETHROSCOPY 


When  a  stronger  current  is  used  and  the  electrodes  have  a  very  much 
smaller  surface,  the  albuminoid  matter  is  coagulated  and  we-have  ''elec- 
trocoagulation. ' ' 

To  j)rodiice  the  maximum  effect  two  electrodes  are  required,  one 
being  very  large  and  wide  and  the  other  very  small.  A  sensation 
of  heat  will  be  produced  near  the  large  electrode,  because  the  heat  is 
spread  over  a  large  surface ;  on  the  other  hand,  the  maximum  electro- 
coagulation will  be  obtained  near  tlie  small  electrode.  In  practice, 
the  wide  indifferent  electrode  consists  of  a  sheet  of  tinfoil  placed  under 
the  buttocks  of  the  patient,  and  the  small  active  electrode  is  introduced 
into  the  bladder  in  direct  contact  with  the  tumor. 

The  small  electrode  consists  of  a  perfectly  insulated  copper  wire 


BEESL\UER  -  LOWE\STEI\  -  PARIS 

Fig.   203. — Current   transformer    for   electrocoagulation. 


Jiaving  a  copper  tip  at  its  end,  which  comes  into  contact  with  the 
growth.  Its  caliber  is  not  quite  that  of  a  ureteral  catheter,  being  easily 
passed  into  a  catheterizing  cysto scope  and  much  more  easily  into  a 
direct  vision  cystoscope. 

RBFEREN-CES 

iDoyen:     L 'electrocoagulation,   Tliird  International  Congress  of  Physiotherapy,  reports  and 

communications,  pp.  556-560. 
aNagelschmidt :      Effets  thermiques   produits  par  les   courants   de   haut  frequence,   Archives 

d'electricite  med.,  March  10,   1910,  pp.   161-173. 
sDoyen:     Therap.  chir.,  Paris,  1910,  iii,  71. 

•iBeer:     Jour.  Am.  Med.  Assn.,  May,  1910;  also  Med.  Eec,  New  York,  Feb.  S,  1913,  p.  242. 
sBuerger  and  Wolbarst:     New  York  Med.  Jour.,  Oct.  29,  1910. 
6G-ardner:     Am.  Jour.  Deimat.  and  Genito-urin.  Dis.,  January,  1912. 
^Sinclair:     Am.  Jour.  Urol.,  March,  1912. 
sMcCarthy:     New  York  Med.  Jour.,  Sept.,  1912. 


TREATMENT    OF    l'.l.AI»|)l-:i:    TCMOIIS  349 

fljiuld :     Jour.  Am.  ^Mcil.  Assn.,  November,  ]!»12. 
loHarpstcr:      Am.  .Iimr.   Surg.,  Jan.,  1913. 
iiBiniifv:     Jioston  Med.  and  Surg,  Jour.,  Feb.,  l!»i;'.. 
)->Wats()ii:     Urcd.  and  Cutan.  Rov.,  Fel).,  191:',. 
'■'•Pil(dier:      Am.  Jour.   Surg.,  April,   191. '5. 
1 'Barney:      Boston   Med.  and   Surg.  Jour.,  .July,    191.".. 
i^Bachracli :      [''olia   Trologica.  .liily,   19i:i. 
i«Kuttner:      Internat.  Cong.  med.  Sc,   Lcjiidoii,   Aug.,    191;!. 
I'Bucky  and  Frank:     Miinch.  med.  Wchnschr.,  Feb.,   191.".. 
I'^Legueu:      Arch.  urol.   de  la  clinique  de   Necker,    I'ari.^.    19i;;,    i. 
mlloitz-Boyer  and  Cottenot :     Assn.  d'urol.,  1911,  p.  771. 
-oAndre:     Assn.  frane.  d'urol.,  Oct.,  1913,  p.  736. 
2iLepoutrc  and  d'Halluin:     Eev.  clin.   d'urol.,  Jan.,   1914,   p.   .".o. 

Operative  Technic. — Tlie  tuclmic  will  vai-y  a'-(  oi'diii;^-  to  wlielJier 
the  indirect  or  direct  cystoscope  is  used. 

1.  With  the  Iistdirect  Method. — The  patient  is  placed  in  ilic  nsnal 
])Osition  for  indirect  cystoscopy.  Tlie  hhnhler  is  tilled  witli  :2(J0  c.c.  of 
sterile  water  and  the  electrode  is  introduced  in  the  same  manner  as  a 
ureteral  catheter,  under  control  of  the  eye,  and  In-ouft-ht  into  direct 
contact  with  the  tumor.  The  current  is  turned  on  for  fifteen  to  thirty 
seconds,  at  each  application;  the  changes  produced  by  the  action  of  the 
current  are  kept  under  close  Avatch  all  the  time.  At  first  gas  hubbies 
will  appear,  then  the  tumor  will  show  a  ])lack  central  zone  surrounded 
by  a  whitish  coagulated  area. 

Generally  the  treatment  must  be  interrupted  because  the  vesical 
fluid  soon  becomes  cloudy.  In  this  case  the  cystoscope  is  withdrawn 
and  the  patient  is  instructed  to  urinate;  considerable  broken-down 
debris  of  the  coagulated  tumor  will  be  found  in  the  urine  thus  passed, 
[In  the  improved  American  cystoscopes,  cleansing  of  the  bladder  is 
accomplished  by  merely  removing  tiie  telescope  and  irrigating  tlie 
bladder  through  the  cystoscopic  tube,  which  remains  undisturbed 
throughout  the  treatment. — Editor.] 

2.  With  the  Direct  Method.— In  general,  the  technic  is  the  same 
as  that  in  direct  vision  cystoscopy.  The  patient  is  placed  in  the  in- 
clined position,  a  large  indifferent  electrode  is  placed  under  the  but- 
tocks, the  cystoscopic  tube  and  the  lam])  are  intioduced  and  the  small 
electrode  is  directed  upon  the  tumor. 

There  is  a  decided  difference  in  the  application  of  electrocoagula- 
tion between  the  two  instruments,  tiie  direct  vision  method  having 
distinct  advantages.  The  fluid  distending  the  l)la(lder  will  offer  greater 
resistance  to  the  current  than  that  offered  by  the  air,  as  in  the  direct 
vision  method.  Furthermore,  the  electricity  will  produce  a  certain 
amount  of  decomposition  of  the  water,  wliicli  is  made  evident  by  the 
escape  of  gas  bubbles  and  by  numei'ous  small  explosions  during  the 


350  CYSTOSCOPY    AN^D    UEETHEOSCOPY 

coagulation.  According  to  some  autliors,  tliese  explosions  are  of  no 
consequence;  nevertheless,  altliougli  the  patient  is  not  aware  of  them, 
they  impair  the  clear  view  of  the  operator  to  some  extent  at  least. 

With  the  direct  cystoscope,  the  technic  is  therefore  much  more 
simplified  because  these  water  inconveniences  are  not  present  in  the  air 
medium.  With  this  instrument,  a  tumor  of  the  bladder  may  be  con- 
sidered outside  of  the  body,  and  can  therefore  be  treated  like  any  other 
tumor  of  the  cutaneous  surface. 

Certain  j)recautions  are  necessary,  however,  when  this  instrument 
is  used.  First,  the  tumor  surface  must  be  thoroughly  anesthetized, 
by  the  aiDplication  of  tampons  soaked  in  a  10  per  cent  solution  of 
stovaine.  After  a  few  moments  the  active  electrode  may  be  safely  ap- 
plied, providing,  however,  that  only  weak  currents  are  employed. 
When  the  current  is  too  strong,  the  patient  will  suffer  pain  and  moves 
about  uneasily,  so  that  the  operation  can  not  be  contiimed. 

On  the  other  hand,  when  the  anesthesia  is  thorough  and  the  cur- 
rent weak,  electrocoagulation  can  be  done  painlessly,  but  the  opera- 
tion progresses  slowl}^  and  the  sittings  must  be  lengthy,  with  little  to 
be  done  at  each  sitting.  With  patience,  however,  the  results  obtained 
are  worth  while.  In  particular,  there  is  no  bleeding.  The  electro- 
coagulation produces  a  very  Avliite  eschar  which  penetrates  deeply, 
and  the  base  of  the  tumor  can  be  attacked  safely  without  fear  of  in- 
jury to  the  bladder  wall. 

It  can  thus  be  seen  that  a  large  tumor  can  not  be  destroyed  in  one 
sitting.  It  is  better  by  far  to  employ  repeated  sittings  to  insure  its 
complete  destruction. 

Eecentl}^  I  used  this  method  in  a  female  iDatient  at  Broca  Hospital, 
in  the  service  of  Jeanselme.  She  complained  of  cloudy  urine.  C^^stos- 
copy  revealed  a  tumor  (Fig.  204).  Electrocoagulation  was  performed 
with  my  direct  vision  cystoscope,  under  most  favorable  conditions. 
The  changes  and  final  results  of  the  treatment  are  Avell  shown  in  Figs. 
205,  206,  207,  and  208. 

Comparative    Value    or    Electrocoagitlatiojst    and 
Galvanocauterization 

Unfortunatel}^  the  comi^arative  therapeutic  A'alue  of  these  two 
methods  has  not  yet  been  sufficiently  studied,  and  it  is  interesting  to 
consider  which  procedure  is  to  be  preferred. 

Advantages  of  Galvanocauterization. — 1.  It  is  simple.  The  use 
of  the  cautery  is  very  simple.  A  galvanic  current  can  be  provided 
easily  in  any  surgical  equipment.     The  manipulation  of  the  current  is 


THKATMEXT    OK    IJI.ADDKK    TTMOItS 


351 


Fig.   204. — \'ie\v   of   a   bladder   tumor   situated   in   median   line   of   the   trigone, — before    treatment. 

SO  simple,  so  convenient,  tliat  it  constitutes  an  ideally  simple  tlieraiieu- 
tic  agent. 

2.  It  is  safe.     The  galvanocantery  is   so  thoronglily  under  con- 


Fig.   205. — Same   as    Fig.  204.      First   application    of   electrocoagulation.      With    the   direct   vision   cystoscope, 
the  excavation   made  by  the  burning  at   the  base   of   the   tumor   is   easily   seen. 


352 


CYSTOSCOPY   AND    UKETHROSCOPY 


F;g.    206. — Same   as    Fig.    204.      View    of   the    same    tumor    eight    days    after   the    first   application    of    electro- 
coagulation.     The   apex   of  the  tumor  is   lower   and   much  smaller   in  front. 

trol  that  it  is  impossible  to  cause  injury  to  tlie  bladder  mucosa.  Neither 
perforation  of  the  bladder  nor  subsequent  hemorrhage  has  ever  been 
observed  in  my  exjierience. 


Fig.  207. — Same  as    Fig.    204.      Second   application    of    electrocoagulation.      The    base    of    the    tumor    is    com- 
pletely  burned;    its   apex  presents   a   white   eschar. 


TRKA'I'.MKXT    OF    i'J.ADIiK):    'IT. MORS 


&.)6 


3.  It  is  painless.  Galvaiiocaiilciizalioii  of  hladdor  tumors  is  re- 
mail<al)Iy  ])ainloss.  I^iin  is  Iclt  only  wlicii  tlic  cautery  l)uriis  tlic 
liealtliy  mucous  m(Mn])i-aiic.  When  pain  is  complained  of,  it  is  an  ex- 
cellent indicalion  llial  tlic  cauterization  lias  readied  the  base  of  tlie 
tumor. 

4.  Its  final  results  are  perf(^ct.  Scars  examined  years  after  cau- 
terization have  always  appeared  smooth,  soft,  and  re,<2,ular. 

5.  Kecnrrence  in  situ  has  never  been  observed  wlien  the  cauteriza- 


tion has  been  done  thorou,2,hly 
soft,  and  well  defined. 


The  cicatiix  always  remains  ^vliite, 


Fig.   208. — Same  as   Fig.   204.      \'ie\v   of   the   bladder   fifteen   days   after   the  application   of   electrocoagulation. 
The   tumor   has   completely   disappeared;   the  vesical   floor   shows   nothing  but   edema. 

Disadvantages  of  Galvanocauterization. — 1.  The  length  of  the  treat- 
ment. It  is  out  of  the  question  to  believe  that  a  tumor  of  considerable 
size  can  be  destroyed  in  a  single  sitting;  repeated  sessions  are  often 
necessary.    But  this  applies  just  as  well  to  electrocoagulation. 

2.  The  action  is  superficial.  Galvanocauterization  does  not  pene- 
ti'ate  deeply  into  the  tissues.  It  is  a  "l)lade  of  lire"  wliicli  destroys 
only  that  which  it  touches.  However,  this  disadvantage  applies 
only  when  we  are  dealing  with  a  malignant  tumor  of  the  bladder. 
In  point  of  fact,  papillomata  are  superficial  tumors  and  in  the  vast  ma- 
jority of  cases  galvanocauterization  is  i^erfectly  able  to  destroy  them 
completely  and  j^revent  their  recurrence.     In  cancer  of  tlie  bladder, 


354  CYSTOSCOPY    AXD    URETHROSCOPY 

llie  galvanocautery  is  manifestly  insufficient;  on  the  other  hand,  the 
most  enthusiastic  supporters  of  electrocoagulation  do  not^m]j]oy  this 
method  in  vesical  cancer. 

Advantages  of  Electrocoagulation. — 1.  Electrocoagulation  has  a 
decidedly  more  powerful  action  than  the  cauterj^;  it  penetrates  more 
deeply  and  is  much  more  intense. 

2.  Electrocoagulation  causes  destruction  of  bladder  tumors  almost 
hloodlessly.  During  the  operation  not  a  drop  of  blood  is  seen;  it  seems 
to  have  a  most  perfect  and  certain  hemostatic  action. 

Disadvantages  of  Electrocoagulation. — 1.  It  requires  complicated 
and  highly  expensive  instruments. 

2.  The  dangers  are  many;  e.g.,  perforation  of  the  bladder  has  oc- 
curred in  many  cases. 

3.  Hemorrhage  is  not  produced  at  the  time  of  operation,  but  eight 
or  ten  days  thereafter,  Avlien  elimination  of  the  escliar  takes  place; 
tliis  accident  has  also  been  reported. 

4.  Electrocoagulation  seems  to  me  more  j^ainful  than  galvanocau- 
terization.  Whichever  method  is  employed,  one  thing  is  certain :  The 
operation  is  much  simj)ler  with  the  direct  cystoscope  than  with  the 
indirect. 

Endovesical  Teeataeext  of  Bladder  Tumors  by  Electrolysis 

Rudolph  Oppenheimer,  of  Frankfort,^  has  i^roposed  that  ijaj^illo- 
mata  of  the  bladder  be  treated  by  electrolysis. 

Operative  Technic. — The  positive  pole  connected  with  a  wide  elec- 
trode is  placed  on  the  patient's  thigh.  The  negative  pole  is  introduced 
into  the  bladder  by  means  of  a  No.  6  Charriere  catheter,  which  is  easily 
admitted  by  any  catheterizing  cystoscope.  The  bladder  is  filled  with 
oxycyanide  of  mercury  solution,  the  cystoscope  is  introduced,  and  the 
A^esical  extremity  of  the  negative  electrode  is  applied  to  the  villi  of 
the  tumor  down  to  its  base.  The  current  is  then  applied,  care  being 
taken  not  to  use  more  than  25  to  45  milliamperes.  By  moving  the  cysto- 
scope about  in  different  positions,  the  electrode  will  attack  various 
parts  of  the  tumor. 

During  the  operation  numerous  gas  bubbles  will  be  seen;  these  are 
due  to  the  electrolysis  of  the  vesical  fluid.  These  air  bubbles  are  often 
so  numerous  as  to  impair  the  operator's  view.  To  correct  this  mishap 
the  author  recommends  enij)tying  the  bladder  and  then  refilling  it. 
After  the  operation  the  patient  voids  fragments  of  the  tumor  of  a  Avhit- 
isli  color  for  about  ten  days. 

Advantages. — The  principal  advantages  which  the  author  claims 
for  this  method  of  treatment,  are  the  folloA\ing: 


ti;|';atmI':x'i'  of  p.ladkki;  'rr.Moiis  .).).) 

1.  II  is  s.-iTc.  Tlic  li('iii(>i-ili;i,i;('  i--  reduced  lo  n  iiiiiiiimiiii.  Ol'leii 
cN'cii  llie  Ncsical  lliiid  is  pei-reclly  clenr  .Ml'ter  lliis  iiilei-\cii1  ion.  As 
t'oiiip;ii'('(l   willi  ('led  |-o('oaeul;d  ion,  llie  dnn^ci'  of  peiToi'al  ion   is  sliidd. 

'2.  It  is  simple.  Tlie  leclinic  is  \'er\'  simple  and  iMMpiires  no  coni- 
plicalcd  a])|)aralus. 

.').  The  Pain  is  Minimized.  W'lieii  the  cntaneons  clcetrode  causes 
a  sensation  of  huiaiiiii;',  it  is  rcliex'ed  hy  intcrposin.L!,'  wd  compresses. 
Tlie  \'esical  electi'ode   is  ahsolutel \'   painless. 

Disadvantages  of  Electrolysis. — First,  tlie  pi'oduction  of  ,uas  bub- 
bles as  a  I'csidt  of  electi'olysis  of  tlie  vesical  medium.  This  necessitates 
em])tyiiii;'  and  relillin,<;'  tlie  bladder.  Hdieii  the  ti-eatment  is  of  loiiLi,-  du- 
i-ation;  a  certain  case,  ti'eated  by  the  author,  recpiired  nineteen  a|>pli- 
catioiis  to  bi'in.jj,'  about  a  cure. 

REFERENCE 

i()p])Oiilioiniov:      Die   intiiivosikfilo  P.oliMiidluni;-   dor   P>lns('iipa])ill()iiir    dnii-li    l';i('i-tr()ly.s(',   Zts-flw. 
f.    rrol.,   1!)];],   iii,   72S. 

Endovesical  Treatment  oe  Bladder  Tumors  ry  Radiu^e 

This  metliod  of  treatirient  has  not  yet  been  very  fully  studied,  but 
it  -does  not  seem  to  me  as  thougli  it  were  able  to  produce  l)rilliant  re- 
sults. I  have  liad  the  opportunity  of  using  it  in  a  ease  myself,  hut 
without  appreeial)le  I'esult.    The  following  is  a  report  of  the  case: 

A  Case  of  Cancer  of  the  Bladder  Treated  hy  BadiiiniA — A  man,  aged  sixty-five  years, 
fatlier  of  a  colleague,  ^^•as  referred  to  me  by  Peraire,  in  .fuue,  IviOi).  Cystoscopy  revealed 
a  lobulated  tumor,  the  size  of  a  cherry,  without  villi,  \Yith  a  liard  and  scirrhous  aspect. 
There  was  no  bleeding.  This  tumor  had  developed  on  a  vesical  trabeculation  behind  and 
outside  of  the  left  vireteral  orifice.     Both  ureteral  orifices  were  absolutely  normal. 

I  suggested  excision  of  a  portion  of  tlie  growth  for  microscopic  examination;  but  the 
patient  was  very  stout  and  his  urethra  was  not  very  patent,  so  I  began  by  passing  sounds  up 
to  No.  60,  ordering  a  fat  reduction  cure  at  the  same  time.  This  treatment  was  followed -by 
good  results,  and  one  riionth  later,  I  was  able  to  cystosco])0  him  and  extract  a  few  fragments 
of  the  tumor.  These  fragment.s,  examined  by  P.  Anuniille,  sliowed  the  ]irosence  of  a  mota- 
typical  pavement  e[)ithelioma;  the  rejtoit  was  at'conipaiiicd  l>y  tliis  (niinion.  ''It  seems  to  be 
of  a  ver_y  malignant  type." 

I  suggestcil  su|)ra])iiliic  cysttitoniy,  not  only  to  be  able  to  leniove  the  tunun-,  luit  also  to 
excise  ^lart  of  the  vesical  wall;  but  th(^  patient  refnsi>d  to  ^^ive  his  consent,  lie  went  thus 
without  treatment  for  a  year.  1  saw  him  again  in  Oclolicr,  Utld;  cystoscopy  showed  that 
the  tumor  had  gi-own  c.nisidcralily  and  that  ils  base  \-.as  ;;s  laigc  as  a  1i\i'  franc  piece 
(silver  dollar).  Surrounding  ils  liasc  wa.s  a  c./nsidcraldc  cdeinalous  area  which  extended  to 
the  prostate  and  completely  obscured  the  left  ui'eteral  (oitice.  Moreover,  the  general  condi- 
tion was  bad,  the  ])atient  having  lost  fifteen  pounds  in   two   mcuiths. 

In  this  condition,  o|u'ration  being  consideriMl  dangerous,  T  ]iioposed  the  application 
of  radium.  The  first  ajiplication  was  made  on  October  :2!i,  with  the  assistance  of  Desgrez, 
whose  skill  in  radicdogy  is  well  known.  Two  tubes  of  radium  in  an  elbowed  catheter  No. 
lil,    were   applied    to    the    tumor.      Sexcn    a]iidical  ions    weri'    made    from    October    to    December. 


356  CYSTOSCOPY   AND    URETHROSCOPY 

The   duration   of   each   treatment  was   about   two   hours,   five   centigrams   of  radium   bromide 
being  used.     Tliis  in  reality  contained  only  two  centigrams  of  radium.         «*• 

Under  this  treatment,  it  was  noted  that  there  was  a  distinct  improvement  in  the  gen- 
eral condition  of  the  patient.  The  hematuria  disappeared,  the  pains  diminished  considerably, 
but  cystoscopy  showed  that  the  edema  surrounding  the  tumor  was  very  much  increased,  thus 
doubling  the  size  of  the  growth.  In  May,  1911,  another  examination  showed  that  both 
tumor  and  its  surrounding  edema  were  progressing  materially.  A  few  months  later  the 
patient  died. 

It  seems  then  that  this  case,  studied  histologically  and  treated 
well  radiologically  by  a  competent  specialist,  and  also  well  treated 
from  the  cystoscopic  point  of  view,  did  not  benefit  by  the  radium  treat- 
ment. The  only  result  obtained  was  the  cessation  of  the  hemorrhage 
and  pains,  but  the  application  of  the  radium  did  not  stop  the  continued 
development  and  growth  of  the  malignant  tumor. 

EEFERElSrCE 

iLuys:     Bull,  et  mem.  Soc.  de  chir.  de  Paris,  1914. 

Note. — The  experience  of  American  urologists  with  radium  in  the 
treatment  of  vesical  cancer  may  be  summed  up  in  the  following  per- 
sonal communication  from  Winfield  Ayres,  of  New  York,  who  has  had 
considerable  experience  with  this  remedy. — Editor. 

"After  nearly  four  years  of  experimentation,  I  am  forced  to  the 
conclusion  that  radium  in  the  treatment  of  cancer  of  the  bladder  is  not 
so  effective  as  in  treatment  of  neoplasms  in  other  parts  of  the  body. 
It  has  considerable  action  in  relieving  the  pain,  but  practically  none  in 
stopping  discharge  or  odor;  and  very  little  in  arresting  the  progress  of 
the  disease  in  the  majority  of  cases. 

''The  most  effective  method  of  application  in  a  well-developed 
cancer  is  by  cross  irradiation  from  the  rectum  to  the  suprapubic  region, 
using  massive  dosage — not  less  than  3,000  mg.  hours  at  a  sitting.  For 
a  small  growth,  this  combined  with  frequent,  direct  applications  of 
the  beta  rays  under  direct  vision  gives  the  most  satisfactory  results. 
Intravesical  applications  without  visual  control  seem  to  me  to  be  too 
dangerous  and  too  haphazard. 

"Cancer  of  the  bladder  should  be  irradiated  before  and  after  op- 
eration. 

' '  Thorough  irradiation  of  a  pajDilloma  not  only  renders  such .  a 
tumor  more  easily  removed  by  dessication,  but  diminishes  the  prob- 
ability of  its  return." 


'ni'KA^r.\lKXnM)K  KOU'KKiX   I',()l)lh:S  IX  TIM';   r>LAI)i)h:iJ 

l^'()f('ii;ii  Ixxlics  ill  the  hhuMcr  arc  <\\'  1\\()  principal  x'ariclics; 
iiaiiicl\\  aclual   forci.^'ii  Inxlics  and  calculi. 

ACTUAL  FOREIGN  BODIES 

The  untoward  coiiseqnciiees  of  foToi,t>,n  IkxIIos  left  in  tlio  Madder 
are  very  well  known. ^  Calcai'coiis  sails  ai'c  dcjjositcd  upon  lliciii,  lliiis 
acting  as  nuclei  of  vesical  calculi.  Tlie  ol)jects  found  in  tlu^  bladder  arc 
varied  and  often  most  unexpected  in  character.  'J'lie  freriiuMicy  of 
fragments  of  bougies  and  catheters  is  easily  explained;  l)iit  it  is  sur- 
prising to  find  hair  pins,  beans,  pencils,  pendiolders,  sticks  of  Avax, 
needles,  and  even  smoking  pipes!  It  is  needless  to  attempt  to  explain 
the  purposes  underhdng  the  introduction  of  these  objects.  Once  the\' 
are  in  the  bladder,  what  is  to  be  done  to  remove  them? 

First  of  all  the  presence  of  the  foreign  body  must  be  made  certain, 
either  by  an  ordinary  metallic  searcher  or  better  still,  by  the  cysto- 
scope.  Their  extraction  is  somewhat  difficult.  AVlien  small  they  can  be 
extracted  with  Collin's  ingenious  extractor  or  with  tlie  lilliotiite. 
These  instruments  can  be  used  onl}^  when  the  foreign  ])odies  are  firm  in 
consistency;  but  in  a  bladder  that  is  irregular  and  trabeculated,  it  is 
difficult  to  determine  whether  the  instrument  is  grasping  the  vesical 
wall,  a  vesical  column,  or  a  soft  foreign  body. 

The  extraction  of  large  foreign  bodies  is  more  difficult.  Long  and 
rigid  bodies  not- more  than  seven  or  eight  centimeters  in  length  gen- 
erally lie  transversely  in  the  bladder  because  this  diameter  never  varies 
even  when  the  bladder  is  evacuated.-  When  caught  in  this  transverse 
position  their  extraction  is  impossible.  It  then  becomes  necessary  to 
change  their  position  from  transverse  to  anlci-o])o<terior,  so  that  they 
will  follow  the  same  roulc  that  llicy  look  wlicii  iiilroduced, — lint  in  llic 
opposite  direction. 

This  can  nol  be  done  1)lindly.  AVlieii  I'oi'cign  bodies  are  to  l)e  i"e- 
inoved  through  the  urethra,  it  is  exideiil  that  their  rapid,  certain,  and 
safe  extraction  can  be  assured  onl\  with  the  eystoscope  under  control 
of  the  eye.  Until  recenlly,  if  simple  means  did  not  succeed  in  recov- 
ering the   l»od\-,   it    was   !iecessai-\    to   resort    lo   sii]irapul)ic   cystotomy. 


PLATE  XXIV 

Fig.  1. — Tesical  tumor  photographed  iu  color  several  hours  after  cystotomy. 

Fig.  2. — Cancer  of  the  Madder  secondary  to  utei'ine  cancer. 

Fig.  3. — Bullous  edema  of  the  iladder,  following  uterine  cancer  in  a  T)a- 
tient  in  the  service  of  Pozzi,  at  Broca  Hospital,  opeiated  on  twice  for 
cancer  of  the  uterine  neck;  after  invading  the  vesicovaginal  wall,  the 
cancer  perforated  the  bladder. 

Fig.  4. — Purulent  ejaculation  from  a  ureteral  orifice,  in  case  of  pyone- 
phrosis. 


KiK.   1. 


Fig.  2. 


Fig.  3. 


TKKAT.MK.VI'    O  I'     l'(  )I;K1( ;  N     IIODIKS    IX    TIIK    lil-ADDKi; 


359 


TTowevcr  safe  lliis  inclliod  iii;i\'  lie,  in  cxix-i-ii'iiccil  liaiids,  the  i-ciihmIv 
seems  out  of  ;ill  pro  port  ion  lo  1  he  cliaractrr  (if  1  lie  1  rouhlc 

II  is  clear  llial  dircci  \i>ioii  cystoscopy  niiisl  Ix'  con-idcrcd  n  \al- 
iial)lc  iirlp  ill  llic  ('\li-aclioii  of  I'oi'cii^n  l)odi.'s  froiii  llic  Madd'-r.  Willi 
this  iiiclliod  llic  rorci,L',n  lio;ly  can  lie  seen  di>1ihctly.  ils  cxacl  position 
is  (Ictcrniincd,  and  it   can  lie  i^raspc*]  cjTcc1i\-cl\    and   ra.pidix'  cxI  racti'd. 

Idns  is  exact  ly  w  liat  liappeneil  in  the  case  of  a  woman,  au'ed  t\\i'nt\'- 
six   ^■eal■s,   win)   nnl'ort  nnatel  \'    lost    a   cellidoid    liaii-   pin    in    lier   liladder 


Fig.   209. — Celluloid    linii|iin,    afttr    having   lain    in    tin-   lil.iclilir    nine    days,    extracted    with    the    direct   vision 
cystoscope.      'I'he    ends    are   already    enernstc<l    with    ealeareous    salts. 

(Ki.i;'.  209).  Slie  re])orled  lier  loss  to  I)OS(pielle,  oT  .Mont Ix'liard.  w  iio 
referred  tlie  woiiian  to  me.  On  J^'ebniai'S'  .'!,  19()(i,  she  lol<]  me  thai  the 
''accident"  liad  occurred  on  January  25,  that  is,  uine  da\'s  pre\ioiisly. 
Idle  ])in  \\as  introduced  into  tlie  uretlira,  eonvexity  tirst,  and  passim;' 
llirou.u'li  the  s))liiucter,  it  Tell  into  tlu'  l)la(l<ler.  Sinee  tlir'n  tlie  patient 
eoin])laine(l  of  ]jain  and  fre<iueiit  urination.  'Idiere  was  no  liematiiria, 
but  tlie  urine  was  cloudy. 


Fig.   210. — Forceps    for   the    extraction    of    foreign    bodies    through   the   direct   vision    cystoscope. 

I  introducetl  my  cystoscope  easily  into  tlie  bladder  and  llie  pin  was 
seen  lyiuii,-  in  tlie  classic  transvei'se  ])()sition.  The  comexity  of  the  ])iu 
pointed  to  the  ri,ii,'lit  of  tlie  ])atient.  To  ,u,ive  the  ])in  an  anteroposterior 
])Osition,  1  inclined  mv  instrument  to  the  rii;-lit,  can.^lit  the  loop  with  a 
force|)S  (l^'i,!!,-.  21(1)  introduced  into  the  cystoscopic  tiihe.  and  tuniinu-  the 
pin,  hroui-ht  it  ai'ound  so  thad  its  convexity  ai)pi-oaclied  the  internal 
orifice  of  the  urethra.  II  was  then  very  easy  to  withdraw  the  instru- 
ment to,^-etlier  with  the  pin.  The  ojieratioii  was  easy  and  ])aiiiles<.  The 
])in  had  followed  the  same  route  coiniiii;-  out  as  it  did  ,H()in,u'  in,  hut   in 


360  CYSTOSCOPY    AND    Ur^ETHEOSCOPY 

an  of)j)Osite  direction.  Tlie  time  required  for  tlie  extraction  did  not 
exceed  five  minutes. 

Examined  after  extraction,  tlie  pin  was  found  to  l)e  made  of  cel- 
laloid,  and  the  branches  measured  7^2  centimeters  in  length.  At  the 
points,  a  slight  incrustation  with  calcareous  salts  could  he  -noticed. 
The  patient  did  not  suffer  any  inconvenience  and  was  able  to  take  the 
train  home  the  same  day. 

This  method  of  extraction  is  extremely  easy  and  joractical  for 
smaller  bodies,  like  the  tip  of  a  catheter,  for  example.  To  illustrate: 
A  woman,  aged  forty-seven  years,  was  ojDerated  on,  at  the  Charite,  on 
August  28,  1905,  by  Auvray,  in  the  service  of  Reclus.  After  the  opera- 
tion, it  was  decided  to  tie  in  a  Pezzer  catheter,  but  the  extremity  of  the 
catheter  broke  off,  while  it  was  being  introduced,  and  fell  into  the 
bladder.  It  was  impossible  to  extract  it  with  ordinary  methods.  On 
September  27,  I  used  my  cystoscope  and  extracted  it  without  mij  dif- 
ficulty (Fig.  211).    In  these  cases,  as  in  any  other  surgical  intervention. 


Fig.   211. — Fragment   of  a   Pezzer   catheter,   broken   off  in  the   bladder;    removed   through  Ivuys'   direct   vision 

cystoscope.      (Twice   the   natural  size.) 

the  rational  princijole  of  seeing  the  lesion  before  treating  it,  must  be 
realized, 

I  had  the  opj)ortunity  of  j^^eeing  another  interesting  case  in  the 
service  of  Pozzi,  at  Broca  Hospital.  It  was  in  a  woman  who  had  been 
operated  on  at  some  other  hospital  for  vesicovaginal  fistula,  silk  su- 
tures being  used.  After  tlie  operation,  the  patient  complained  of 
cloudy  urine.  With  ni}^  cystoscope,  I  discovered  a  small,  white,  mov- 
able calculus  in  the  bladder,  and  a  silk  thread  situated  on  the  side  of 
the  bladder  (Plate  XI,  Fig.  1). 

It  is  interesting  to  note  that  in  this  case,  as  in  almost  all  similar 
cases,  the  silk  thread  which  united  the  vesicovaginal  wall,  was  tied 
on  the  vaginal  side.  It  often  happens,  however,  that  the  knot  becomes 
rotated  toward  the  bladder.  This  is  exactly  what  happened  in  this 
particular  case.  The  small,  white  calculus  was  evidently  due  to  the 
presence  of  a  piece  of  silk  thread  which  remained  in  the  bladder.  The 
calculus  was  eliminated  with  the  urine,  a  little  later,  through  normal 
urination.  The  silk  thread  was  caught  at  the  knot  with  a  pair  of  for- 
ceps and  gently  pulled  out  in  its  entirety. 


TREATMKXT    OF    FOIMCIOX    T.ODIKS    IX    TIIK    BLADDER  3GI 

MniiN'  iiilcrcsliiiL;-  cases  liavc  hccii  rcpoiiiMl  l»y  various  authors. 
Tlic  foliowiiift-  are  aiiion^'  ili<'  most   iiiij)oi1aiil : 

Boai'i,  oF  Aucono,  \\>^ri\  my  iiisl  fniiicnt  siicccsvl'ully  in  a  jtaiiicu- 
larly  iiiipoi-laiil  ('as(\  T]\('  Icl'l  iirclci'  was  iiijiir<M|  (liirini;-  an  alxioiii- 
iiial  hysterectomy  for  lihroma.  lie  iiil  loduccil  a  Xo.  i)  ui-clcral  catheter 
into  the  uret(  i\  so  tliat  its  peripliei'al  exti'emity  eiitei-ed  the  hhuhhT. 
Then  Jie  sutured  the  ureter  over  and  around  the  catheter.  'I'iie  (j])ei-a- 
tive  sequelae  were  regular  and  uueventt'ul,  and  tweKc  days  latei-  Boari 
used  my  direct  vision  cystoscope  and  extracte(l  the  uretei-ai  catheter 
witlioiit  any  difficnity.' 

Gautliier,  of  Lyons,  extracted  a  ])r()ken  catheter  from  liie  l^iadder 
of  a  man,  under  local  cocaine  anesthesia.  His  report  of  the  case  fol- 
lows:'^' 

"X.,  aged  forty  years,  entered  the  Hospital  of  Sainte-Foy-les-Lyon  in  the  service  of 
Gallois,  on  February  20,  1909.  He  was  suffering  from  a  syphilitic  myelitis,  complicated  for 
a  month  past  by  an  almost  complete  paraplegia  and  complete  retention  of  urine.  He  had 
been  catheterizing  himself  with  a  Nelaton  catheter,  which  broke  in  two  in  the  canal.  The 
portion  wliich  remained  outside  was  saved.  On  examination  it  consisted  of  a  red  rubl)er 
catheter  No.  14,  nearly  16  cm.  in  length.  A  similar  catheter  in  perfect  condition  was  fouml 
to  be  32  cm.  long;  consequently  the  piece  left  in  the  bladder  must  have  had  a  length  of 
about  16  cm.  The  rulibcr  was  hard,  cracked  and  inelastic.  It  had  been  'baked'  by  time,  and 
was  easily  broken  in  two.     This  fragility  readily  explained  the  accident. 

' '  The  day  following  his  entrance  into  the  hospital,  Gallois  attempted  to  extract  the 
catheter  with  Collin's  tractor,  but  it  broke;  two  fragments  measuring  two  centimeters  were 
recovered,  however.  This  method  was  not  successful.  My  friend  Gallois  then  invited  me 
to  examine  the  patient.  I  cystoscoped  him  on  February  28  and  found  a  cystitis  with  the 
cloudy  and  foul  urine  characteristic  of  foreign  bodies  in  the  bladder.  After  a  copious  irriga- 
tion of  the  bladder  I  tried  to  remove  the  catheter  with  a  lithotrite  with  flat  jaws.  Anesthesia 
was  unnecessary,  for  the  myelitis  had  brought  about  a  marked  analgesia  of  the  urethra 
and  bladder. 

''I  was  not  any  more  fortunate  than  Gallois,  because  I  did  not  remove  any  more  tlian 
tluee  centimeters  of  nonencrusted  catheter,  in  three  fragments.  I  did  not  persist,  for  fear 
of  causing  trauma  in  an  already  infected  bladder.  It  was  indeed  very  difficult  to  grasp 
the  foreign  body,  because  the  sensation  felt  through  the  lithotrite  was  similar  to  that  which 
is  felt  when  the  mucosa  has  been  caught.  I  postponed  cystoscopy  for  a  few  days  to  give 
the  bladder  a  rest.  In  the  meantime,  the  bladder  was  irrigated  twice  daily  with  a  silver 
solution. 

"On  April  1,  I  performed  indirect  cystoscopy.  The  catheter  was  seen  immediately, 
encrusted  with  calcareous  salts,  which  gave  it  a  whitish  coating  and  thus  made  it  easier  to 
be  seen.  One  end  was  near  the  roof  to  the  right,  the  other  was  to  the  left  of  the  neck. 
According  t(i  the  l;uv  of  accominodatioii  of  Guyon  and  Hcnviet,  this  olilii(ue  position  in  the 
vertical   plane  gav(^  flu^  foreign  body   more   lluui   nine  centiinet  eis   of  length. 

"What  was  to  be  done?  The  usual  instruments  for  extracting  foreign  bodies  were 
fruitless,  owing  to  the  friability  of  tlie  catheter.  AVe  were  not  encouraged  to  try  them 
again,  because  the  encrustation  had  increased  the  size  of  the  object  and  nmde  it  7nore  dan- 
gerous to  the  integrity  of  the  urethral   mucosa. 

"We  thought,  naturally,  of  su|n-apubic  cystotomy,  or  better  still,  of  pcuineal  section, 
which  gave  better  drainage  to  such  an  infected  bladder.  But  the  patient  was  very  nuicli 
depressed,  suffering  from  sulia<utc  myelitis,  and  a  continual  diarrhea  produced  by  the  injec- 


362  CYSTOSCOPY    AND    URETHROSCOPY 

tions  of  mercury  biniodide.  In  these  circumstances  we  were  justified  in  hesitating  before  a 
general  anesthesia  and  a  bloody  operation.  So  we  decided  to  use  the  modern  Luys'  indirect 
rision  cystoscope.     In  case  of  failure,  cystotomy  would  be  resorted  to. 

'^  Having  procured  the  necessary  instruments,  I  cystoscoped  the  patient  on  March  8. 
It  was  my  first  attempt  with  this  instrument  in  the  male,  and  I  think  also,  it  w-as  the  first 
time  this  procedure  was  ever  attempted  in  Lyons.  The  operative  steps  were  as  follows: 
Copious  bladder  irrigations  with  permanganate;  emptying  the  bladder;  urethral  anesthesia 
with  cocaine  (the  patient  having  been  improved  by  the  mercury  injections,  %ad  recovered 
the  urethrovesical  sensation)  ;  large  sounds,  about  30  Charriere  were  passed.  They  tore  the 
meatus  and  caused  slight  bleeding;  the  cystoscope  was  introduced  easily  with  its  elbowed 
obturator,  by  depressing  the  j)ubic  region,  thus  relaxing  the  suspensory  ligament  of  the 
penis  (Guyon's  method).  The  obturator  was  withdrawn,  the  light  introduced  and  the  urine 
aspirated  with  the  water  horn ;   Trendelenburg  position. 

' '  The  catheter  was  seen  heavily  covered  by  calcareous  deposits,  resembling  a  section  of 
pipe-stem  covered  with  white  clay.  It  was  about  ten  centimeters  in  length,  as  was  expected. 
The  position  was  the  same  as  that   observed  with  indirect  cystoscopy. 

''In  order  to  disengage  the  catheter,  its  lower  end  which  was  the  most  accessilile,  was 


Fig.   212. — View   of   the   bladder    mucosa   in   bullous    cystitis,    accompanying    a    foreign    body    in    the    bladder. 
(This   cystitis   covers   two-thirds   of   the   bladder.)      (Le   Fiir.) 

cut  across  with  a  sharp-blade  forceps.  In  this  way  several  fragments  were  witlidrawn 
through  the  urethroseopic  tube.  The  other  extremity,  now  movable,  was  also  seized  a't  its  end 
and  drawn  through  the  tube.  This  fragment  was  six  centimeters  long,  and  its  caliber,  in- 
cluding the  encrustation,  was  No.  22  Charriere. 

"Cystoscopy  then  showed  that  there  were  still  two  small  fragments  in  the  bladder. 
The  mucosa  was  very  highly  inflamed;  small  ulcerations  and  blackish  infiltrations  were  seen 
here  and  there.  A  fetid  odor  came  through  the  tube.  Tlie  patient  was  brought  to  the 
horizontal  position,  and  the  bladder  liberally  irrigated  with  permanganate.  The  operation 
was  well  tolerated   and  thanks  to  the  cocaine,  was  painless. 

"The  final  results  were  satisfactory.  Eight  days  later  (March  15)  tlie  urine  was  less 
cloudy  and  foul,  there  was  no  fever  and  the  tongue  was  moist.  When  all  the  recovered 
pai'ts  of  the  catheter  had  been  added  to  the  part  that  had  been  saved,  we  obtained  a  length 
of  31  cm.,  which  was  just  one  centimeter  less  than  the  perfect  catheter  used  for  comparison." 

Another  case  is  reported  hy  Ferron.®  A  working  girl,  aged  sixteen 
years,  entered  the  service  of  Poiisson  with  symptoms  of  severe  cystitis. 
The  patient  attributed  the  affection  to  overwork,  but  further  question- 
ing elicited  the  admission  that  slie  had  accidentally  inserted  a  metallic 


TIIKATM  KXT    Ol"     I'OKI'.K :  X     I'.OHIKS    IX    TIIK    lU.ADDLIl  6M 

ii;nr|»iii  iiilo  llif  lil;i(lil<'i-.  I>\  the  jiid  <>!'  dii-ccl  ■,i.-i(iii  cysloscojiN',  l'\'r- 
I'oii  i'('C()\('i('(l  llic  olijccl.  Ill  tlii>  cMSc  iiiiliiccl  ('ys1()sc()j)y  was  iiii|)()S- 
sililc  Ix'caiisc  ol'  llic  <'\is1  iiii;-  cxslilis. 

Slill  aiiollicf  \('r\-  iiilci-csliiii;-  case  is  icpoiicd  hy  \.i'  h'iir.  A 
woman  had  liccii  sul>Ji'(d(M|  to  a  suhloial  alxloiiiiiial  li\  .-1cn'cloiii>-  Tor  a 
lihroiiia  ol'  llic  ulcnis.  Al'h  r  llic  o|)cralioi!,  llic  i)aliciit  always  coiii- 
plaiiicil  of  |)aiiis  in  licr  ahdonicn,  and  llircc  inonllis  later,  tlic  suri;-coii 
w'lio  had  opcratcil  on  iici',  found  an  inlillration  ol'  the  xa^iiiai  cul-dc- 
sac,  for  which  he  advised  hot  va,i;inal  douche-.  'I'lie  pains  pei-sistcil, 
howcvci',  in  spile  of  these  iii'i,i;al  ions.  A  diagnosis  of  abscess  of  Hh; 
hi-oad  li,<;aiiient  was  made,  and  a  \a;-;iiial  incision  was  jjci-foi'iiKMl  in 
Febniary,  1  !)()!>. 

Ill  the  i'ollowin.i;'  Au^'ust  anolhci-  sui-,i;<M>ii  made  an  a!)<h)iiiiiial  in- 
cision.     Meanwhile,   in  A])ril,   the   ])atient    liad    he.^un    to   comjilain    of 


Fig.   213. — Three  strands  of  silk  thread   the  ends  of  which  project  into  the  bladder.      (Le   Fiir.) 
Fig.   214. — Three   additional    strands    of    thread,    with    a    knot    projecting    into    the    bladder    (magnilied 
by  the  cystoscope).      (Le  Fiir.) 

pain  in  the  bladder,  and  in  spite  of  the  vaginal  irrigations  and  internal 
treatment  these  pains  continued  to  grow  worse. 

Le  Fiir  saw  the  patient  the  hrst  time  late  in  1909.  The  urine  was 
very  cloudy  and  precipitated  a  thick  layer  of  pus  in  the  examining 
glass.  Cystoscopy  showed  a  very  intense  cystitis,  which  might  have 
])een  mistaken  for  a  neoplasm  of  the  ])ladder.  Local  treatment  was  in- 
stituted and  the  cystitis  improved. 

A  second  cystoscopy  revealed  at  least  four  or  live  masses  ot  thread 
reseml)]ing  silk,  attached  to  the  pwsterioi-  hladder  wall,  and  present- 
ing a  hairy  appeai-ance  owing  to  the  silk  libei-s.  Others  \\ere  covei'ed 
hy  a  whitish  mucus  forming  a  real  veil;  some  had  tlieir  ends  free:  iu 
others  the  knot  of  the  thread  could  be  recogni/ed. 

Le   Fiir  used   Luys'  direct  cystosco2)e  and   he  discoveivd  and  ex- 


364  CYSTOSCOPY   AISTD    TJEETHROSCOPY 

tracted  a  silk  loop  thirty  centimeters  in  length ;  he  thus  avoided  supra- 
pubic cystotomy  and  improved  the  patient's  condition  considerably. 
This  interesting  case  of  the  removal  of  a  silk  thread  of  such  a  length 
(Figs.  213-214)  and  its  extraction  through  my  cystoscope,  indicate 
conclusively  the  great  benefits  that  can  be  derived  from  the  recent 
improvements  in  the  technical  instrumentation  in  c^^stoiscopy.  As 
Le  Flir  well  states  it,  ''direct  vision  cystoscopy  has  succeeded  where 
all  other  exploratory  procedures  have  failed." 

EEFEEENCES 

iLa  Clinique:      April  13,  1906,  p.  230. 

2Henriet:     Ami.  d.  mal.  d.  org.  genito-urin.,  April,  1884. 

3Tr.  Assn.  frang.  d'urol.,  1905,  p.  467. 

iBoari:  Estratto  degli  Atti  della  Societa  Italiana  di  Urologio,  Congresso  Eoma,  April  15,  16, 
1908. 

"Gauthier:     Lyon  nied.,  April  11,  1909. 

eFerrou :     De  la  cystoscopie  a  vision  clirccte.  Thesis,,  Paul  Jardon,  1912,  p.  57. 

7Le  Fiir:  Extirpation  d'une  sole  de  O  m.  30  par  la  cystoscopie  a  vision  directe.  Communi- 
cation to  the  Surgical  Society  of  Paris,  June  30,  1910,  p.  618. 

sLe  Fiir:     Personal  communication,  January  25,   1914. 

TREATMENT  OF  VESICAL  CALCULI 

Vesical  calculi  can  be  extracted  through  the  natural  channels  with 
the  aid  of  the  direct  vision  cystoscope,  only  however,  when  they  are 
not  too  large  to  pass  through  the  urethra.  This  means  that  the  cysto- 
scope is  of  service  only  Avitli  small  calculi;  but  with  phosphatic  calculi, 
whatever  their  size,  direct  cystoscopy  stands  j)reeminent. 

Treatment  of  Phosphatic  Vesical  Calculi 

These  calculi  are  relatively  frequent  and  occur  mostly  in  women. 
At  times  they  develop  around  a  foreign  body  introduced  accidentally 
into  the  bladder;  at  other  times,  the  foreign  body  may  be  introduced 
during  some  surgical  intervention;  this  may  include  a  fragment  of  a 
catheter  or  bougie,  or  a  thread  of  catgut  fallen  into  the  bladder  dur- 
ing the  treatment  for  vesicovaginal  fistula,  or  a  pessary  which  has  ul- 
cerated through  the  vesicovaginal  wall. 

Occasionally  the  foreign  bodies  are  introduced  accidentally;  the 
long  list  of  such  objects  includes  hairpins,  beans,  peas,  pencils,  pen- 
holders, sticks  of  wax,  pins,  pipe-stems,  etc.^  Even  in  a  short  time  they 
may  become  encrustated  by  calcareous  deposits;  and  after  a  certain 
period  they  are  found  covered  by  a  turtle-shell  thickness  Avliich  hides 
them  completely. 

Phosphatic  deposits  may  develoj)  even  without  preexisting  foreign 


TIIKATMl^XT    OF    VKSICAL    ("AT-CriJ  365 

bodies  l»y  siniplc  pivcipilalioii  of  sails  in  a  \r\y  coiicciil  ra1('(l  alkaline 
urine.  As  a  imiIc  IIicn'  arc  llic  itsiiH  of  ii'iproix'i-  aliiii('ii1ai->-  liy,i:'i(Mi(»; 
or  they  ina\-  !)•'  srcondarN-  lo  an  in1cii>c  and  jnolon.ucd  cyslili-.  \\  lien 
they  develop  in  a  previously  licallliy  l.lad.lcr,  llicv  cause  an  in-ilallon 
of  ilie  niueosa,  pi'oducin.i;'  a  se\'ere  and  painful  cx.-lilis.  1'liese  jilios- 
))liatie  deposits  ol'leu  adiiei'e  lo  the  ^•esi(•al  nui('o>a  to  -ueli  a  de,i;-ree  that 
tlu'V  can  not  he  removed  without  tearin--  rra-inent.-  oT  the  nuicosa 
aloui;'  with  them;  tlie>-  look  like  I'eal  stalactites. 

The  i)resence  of  these  deposits  can  he  deleruiined  hy  an  ordinary 


Fig.   215.— View   of   a   phosphatic   calculus   seen   through   I.uys"    direct   vision    cystoscope. 

explorer  or  metallic  searcher;  but  the  surest  way  is  to  see  them  throii.uh 
a  cystoscope.  After  they  have  been  fouiul.  Ihei-e  are  three  methods  of 
treatment:  Lithotrity,  suprapubic  cystotomy  and  sim])le  curettap 
Ihrouo-h  the  natural  channels;  but  all  three  methods  present  serious  dis- 
advantages. 

Crushing  is  insufficient.  The  fiagmeids  ot  calcareous  encrustation 
which  are  adherent  to  the  nnicosa,  are  frequently  too  small  to  be 
grasped  between  the  jaws  of  the  lithotrite;  often  they  are  also  soft, 
which  makes  it  very  difficiUt  to  seize  them  even  with  the  most  careful 
searching  of  the  instrument. 


366  CYSTOSCOPY    AND    URETHROSCOPY 

They  can  uiidoiibtedly  be  removed  tliroiigli  eystotoni}^;  but  the  op- 
eration is  out  of  all  proportion  to  such  a  benign  ailment,  especially 
when  we  consider  the  frequent  recurrences  of  these  deposits.  It  would 
be  absurd  to  advise  another  cystotomy  for  each  recurrence. 

Curettage  through  tlie  natural  channels  is  done  blindly;  fragments 
are  liable  to  remain  in  the  bladder,  thus  injuring  the  heajjthy  vesical 
mucosa. 

The  real  treatment  is  their  extraction  under  the  control  of  the  eye, 
through  the  direct  vision  cystoscope.  This  method  is  radical,  because 
it  enables  the  operator  to  extract  everything;  it  is  simple,  because  gen- 
eral anesthesia  is  not  required;  and  the  patient  can  continue  his  usual 
occupation  immediately  after  the  intervention;  lastly,  it  is  absolutely 
without  danger. 

The  technic  is  simple:  The  cystoscope  is  introduced  into  the  blad- 
der and  the  deposits  are  readily  located  in  the  form  of  calculi  of  shin- 
ing white  color  and  various  sliapes, — round,  oval,  pointed,  stalactite. 
A  forceps  (Fig.  210)  is  introduced  through  the  cystoscopic  tube,  grasps 
the  fragments  and  withdraws  them  (Fig.  216). 

In  certain  cases  there  is  but  one  calculus;  this  is  seen  when  the 
deposit  covers  a  foreign  body.  Sometimes  they  are  multiple,  either 
mobile  or  fixed  to  the  mucosa  or  encysted.  For  the  latter,  the  direct 
cystoscope  is  especially  serviceable.  With  this  instrument  the  entire 
surface  of  the  mucosa  can  be  examined  systematicalh^,  and  the  calculi 
can  be  removed,  one  after  the  other,  with  the  aid  of  forceps  and  with 
the  minimum  injury  to  the  vesical  mucosa. 

The  smallest  and  most  adherent  fragments  are  easily  detached 
and  grasped  by  the  forceps.  Sometimes  a  small  tampon  of  cotton  at- 
tached on  a  probe  is  sufficient  to  detach  and  extract  small  fragments 
which  are  very  friable;  this  converts  the  deposits  into  an  actual  phos- 
phatic  pulp. 

When  the  fragments  are  liard  and  small,  they  can  be  extracted 
through  the  tube.  When  they  are  larger  than  the  lumen  of  the  tube, 
they  can  be  grasped  b^^  the  forceps  and  both  tube  and  forceps  are  with- 
drawn at  the  same  time.  "WTien  the  calculus  is  too  large,  it  may  not  be 
able  to  pass  through  the  vesical  neck.  In  these  circumstances,  because 
of  its  size,  it  is  easily  located  by  the  lithotrite,  which  breaks  it  into 
small  fragments;  the  latter  are  then  located  by  the  cystoscope  and  ex- 
tracted without  difficulty. 

The  postoperative  steps  are  extremeh^  simple:  Copious  vesical  ir- 
rigations with  hot  boric  solution  will  control  any  possible  bleeding. 
There  is  no  necessity  of  leaving  a  catheter  in  tlie  bladder  for  drain- 
age.    The  patient  goes  home,  takes  large  quantities  of  warm  liquid. 


TKIvM'.M  i;.\"'r    OK    NKSICAI,    CALCI'M 


367 


and   iirol  ropiii   is  prcscrilxMl ;  no  oilier  1  icnl  inciil    is   ncccssai'v.     Six  to 
1"ii  (lays  lalci-  cystoscojjy  will  he  rc«|nii-('(l  to  vcril'y  the  i-csult. 

I  have  oflcii  had  tlic  oppoit  nnily  of  a|)|)lyini;-  this  method  ol*  ti-eat- 
nienl.  All  llie  cases  are  icina  rkalile  I'or  llic  .-iniplicilx'  ol'  llie  op<'rarion 
and  llie  excelleiil  |-esnlls  ol  »1  a/i  ikm  I .  TlieN'  occnr  ainiosi  in\'a  rialil  \'  in 
wonieii  alioni  fori)'  years  ol'  a,^«',  who  complain  (tf  I'l-ecpienl  urination, 
cloud}'  and   occasionallx    hloody    urine.     The   jiollakiuria   i.-  .-onietiiiies 


')  Jjupret 


fig.   216. — Extraction    of   a   pliosphatic   calculus    llinnigh    I.iiys'    direct   vision    cysloscoije. 

^'e^y  severe,  eonipellin*;'  tlie  patient  to  xoid  every  ten  minutes,  and  tlie 
pain  after  ni'ination  is  very  acute.  With  tlie  ahove  mentioned  treat- 
ment, the  p'ains  disappeai'  vei-y  ra])idly  and  the  vesical  capacity  ad- 
vances rapidly  i'l'om  20  to  80  and  even  150  e.c.  The  cure  is  materially 
aided  l)y  tlie  local  a])i>licatioii  of  a  .")  or  10  per  cent  niti-ate  of  silver 
solution  through  the  cystoscope,  to  the  points  on  tlie  mucosa  where  the 
calculi  were  implanted. 


368  CYSTOSCOPY   AINTD    UEETHROSCOPY 

Two  cases  are  particularly  interesting  and  worth  reporting.  One 
was  that  of  a  woman,  aged  fifty-five  years,  with  an  extremely  acute 
cystitis  and  numerous  phosphatic  concretions.  On  a  previous  occasion, 
in  February,  1908,  I  extracted  a  great  number  of  phosphatic  masses, 
with  the  aid  of  forceps.  In  July,  1909,  I  repeated  this  procedure  more 
thoroughly;  all  the  calculi  were  extracted  and  the  patient  was  com- 
pletely relieved.  These  calculi  were  examined  by  Carrion,  and  he 
found  they  consisted  of  phosphates  of  ammonia  and  magnesium.  Since 
then  I  have  applied  this  treatment  to  other  cases. 

The  following  case  is  also  of  particular  interest. 

A  woman,  aged  thirty  years,  was  referred  to  me  by  Gauja,  on  May  17,  1912.  For 
three  months  she  carried  in  her  bladder  the  head  of  a  Pezzer  catheter.  During  a  difficult 
confinement,  four  months  previously,  her  perineum  was  torn,  and  sutured ;  an  attempt  was 
then  made  to  introduce  a  Pezzer  catheter  but  its  tip  fell  off  into  the  bladder.  The  urine 
became  cloudy  and  the  microscopic  examination  of  the  centrifuged  deposits  showed  the  pres- 
ence of  pus  and  blood. 

Cystoscopy  revealed  the  presence  of  a  white  calculus,  in  the  shape  of  a  mushroom, 
vaguely  resembling  in  outline  the  tip  of  the  catheter.  On  May  21  this  was  extracted.  The 
cystoscope  was  introduced  easily  and  the  forceps  directed  toward  the  calculus;  the  latter 
being  smooth  could  not  be  grasped,  and  moreover,  even  when  I  succeeded  in  seizing  it  with 
forceps,  it  could  not  be  extracted  because  it  was  too  large  to  pass  through  the  urethra. 
Then  a  lithotrite  was  introduced  and  the  calculus  was  caught  and  crushed  into  small  frag- 
ments. The  cystoscope  was  again  introduced,  the  fragments  were  extracted,  and  among 
them,   portions   of   the   catheter   head  were   readily   recognized. 

The  operative  results  were  uneventful.  On  May  24  the  patient  was  completelj'  cured; 
the  urine  was  clear;  the  cystoscope  did  not  reveal  any  trac«  of  calculi  or  any  other  abnor- 
mality of  the  bladder.  In  this  particular  case,  one  might  have  thought  crushing  alone  would 
have  been  sufficient;  but  the  soft  fragments  of  the  catheter  could  not  be  seized  in  the  jaws 
of  the  lithotrite  and  they  might  therefore  have  become  the  nuclei  of  new  calculi. 

Another  remarkable  and  interesting  case  is  that  reported  by 
Pulido-Martin,  of  ]\Iadrid.^ 

"Mrs.  E.  L.,  aged  thirty  years,  married,  mother  of  three  healthy  children;  no  patho- 
logic history,  normal  menses,  no  miscarriages.  For  a  year  and  a  half,  she  had  noticed  that 
her  urine  was  bloody,  independently  of  her  menstruation  or  pregnancy;  and  without  any  ap- 
preciable cause.  Becoming  alarmed,  she  consulted  a  physician,  who  prescribed  a  hemostatic. 
Several  days  after  the  onset  of  this  attack,  urination  became  frequent  with  pain  at  the  end 
of  the  act;  these  pains  became  continuous  as  the  frequency  increased.  The  urine  when  exam- 
ined, was  purulent  and  alkaline,  with  numerous  phosphatic  deposits.  The  patient  then 
consulted  Angel  Bueres,  a  distingTiished  Asturian  specialist,  who  cystoscoped  her  under  most 
unfavorable  conditions.  The  capacity  of  the  bladder  was  not  more  than  60  c.c. ;  the  blood, 
the  pain  and  the  movements  of  the  patient  made  a  definite  diagnosis  well-nigh  impossible. 
Nevertheless  he  was  able  to  distinguish  a  white  mass  at  the  trigone,  extending  toward  tlie 
left  side.  As  the  vesical  capacity  could  not  be  increased  and  the  pains  persisted,  my  ex- 
cellent colleague  and  friend  referred  the  patient  to  me. 

"She  was  a  large,  stout,  pale  woman,  of  lymphatic  aspect,  who  seemed  tired  out  by 
the  repeated  and  persistent  pains  which  she  had  suffered.  She  voided  every  fifteen  or  twenty 
minutes,  day  and  night ;  urination  was  very  acutely  painful,  especially  toward  the  end ;  oc- 
casionally she  had  attacks  of  acutely  painful  vesical  colic,  when  she  voided  large  phosphatic 
concretions  covered  by  fragments  of  necrotic  mucosa  and  glary  mucus.     The  urine  was  strongly 


TllEATMENT    OF    VESICAL    CALCULI  6b\) 

alkaline  and  fontaincd  a  laifjo  niiniltcr  of  cocci  ami  bacilli,  from  wliicli  tlio  tultoicle  liacillus 
fould  nof  lie  isolalcd.  The  travel  and  llie  lack  of  1  icatinent  liad  reijuced  the  vesical  capacity 
to  40  c.c. 

"As  indiri'i-l  cystoscciipv  was  tlius  inipnsMl  ilc.  I  i  iit  luilnccd  Liiys'  iliicci  cysloscope,  an<l 
saw  a  wliitisli  mass  at  tlic  tri<;one,  Jiavinj;-  tlic  a|i|icaiaiicr  of  ilic  coic  of  a  fiiiuncle.  Numer- 
ous granulations  of  jiliospliat  ic  sails  were  spinid  iiic^ulaily  (ucr-  11h'  mucosa,  and  contrasted 
NJvidly  liy  llicii'  cdldi-  with  tlic  rest  of  the  iircintic  tissues.  TIh'  mucosa  was  ulcerated  in 
soiuc    places    and    I  he    rest    of   IJic    hhiddcr    was    \ciy    rc(j. 

"At  first  1  extiacted  a  few  cuncictinns  with  Kallmann's  foiceps  and  irrigated  the 
bladder  lij^ldly.  Tliis  treatment  was  repeated  in  three  or  four  days.  After  this  tli(!  number 
of  concretions  diminisiicd  and  patient  improved.  Tiicn  I  instituted  the  following  sy.stematic 
treatment:  Tlie  patient  was  put  in  the  Luys'  cystoscopic  position,  the  cystoscope  was  intro- 
duced and  fragments  of  necrotic  tissue  and  concretions  were  extracted  with  Kollmann's 
forceps.  Then  the  white  surface  was  swabbed  with  sterile  absorbent  cotton  on  a  probe,  and 
the  parts  were  then  touched  up  with  a  3  per  cent  silver  nitrate  solution  on  another  probe, 
this  being  followed  by  a  bladder  irrigation.  The  treatment  was  paiidess,  without  local  anes- 
thesia, and  without  hemorrhage,  and  the  patient  continued  hei'  acti\c  social  life  without  a 
single  day's  interruption. 

"The  bladder  condition  improved  at  the  1)eginnin;^  slowly,  then  more  lapidly,  so  tliat 
in  one  month  the  capacity  had  increased  from  40  c.c.  to  200  c.c;  the  pains  had  disappeared, 
the  urine  became  clear  and  recovered  its  normal  reaction.  Cystoscopy  in  a  fluid  medium 
with  indirect  vision  showed  that  the  ulceration,  which  had  been  covered  by  necrotic  masses, 
encrustations  and  numerous  mierobic  organisms,  had  diminished  to  such  an  extent  that  it 
occupied  a  little  round  space  the  size  of  a  cent.  This  ulcer  was  situated  above  the  trigone, 
toward  the  right  side,  but  at  some  distance  from  the  right  ureteral  orifice;  in  its  center,  was 
a  small  phosphatic  deposit  corresponding  to  a  small  wound  situated  on  the  anterior  wall  of 
the  bladder;  this  wound  was  oblong  in  shape  with  its  long  diameter  situated  vertically;  the 
transverse  diameter  was  the  same  size  as  the  ulcer  on  the  posterior  wall  of  the  bladder.  It 
wa,s  certainly  produced  by  friction  of  the  encrustated  ulcer  of  the  posterior  wall  with  the 
mucosa  of  the  anterior  surface.  The  posterior  ulcer  having  })een  treated  locally  was  quickly 
cured,  while  the  nonencrusted  wound  of  the  anterior  wall,  wliieh  was  not  directly  treated, 
took  a  long  time  to  cicatrize. 

"The  only  drugs  taken  internally  during  this  treatment  were  uraseptin  and  a  diuretic 
infusion.  When  the  bladder  capacity  had  become  normal,  and  the  urine  clear,  a  functional 
test  of  the  separate  kidneys  was  made ;  and  as  I  expected,  I  found  the  urine  perfectly  normal. 
The  kidney  function  was  slightly  retarded  and  elimination  seemed  less  rapid  than  in  per- 
fectly healthy  kidneys.  The  patient  has  been  feeling  well  since  then — I  hear  from  her  every 
two  or  three  weeks —  and  has  thifs  been  made  lid  of  a  rebellious  and  painful  illness  in  little 
longer  than  a  month  and  a  half." 

Still  anotlier  case,  also  very  iiileresting,  is  reported  ))y  E.  Escoiiiel, 
of  Arequipa,  Peru,  as  follows:^ 

"A  woman,  aged  forty-eight  years,  presented  herself  for  consultation  for  urinary  fre- 
quency, vesical  tenesmus  and  cloudy  urine,  covering  a  period  of  several  months. 

"Clinical  examination  revealed  a  painful  bladder;  vaginal  examination,  negative.  Tlie 
patient  voided  ten  to  fourteen  times  during  the  twenty-four  hours,  the  total  quantity  never 
exceeding  1600  c.c.  Vesical  capacity  was  200  c.c,  and  when  that  limit  was  reached  she  had 
an  imperious  and  almost  painful  desire  to  void.  Microscopic  examination  of  the  urinary 
sediment  showed  many  leucocytes,  bladder  cells,  a  few  urethral  and  ureteral  epithelial  cells, 
and  numerous  small  cocci.     Earthy  phosphates  were  also  present. 

"Cystoscopy  with  Luys'  instrument,  the  use  of  which  I  had  learned  from  its  inventor 
himself,  revealed  a  chronic  catarrhal  cystitis  and  a  small  soft,  phosphatic  calculus,  firmly 
■  fixed  and  encrustated  at   the  bladder  fundus  and  partly  envcloiicil  by  the  nuicosa. 


370  CYSTOSCOPY    AXD    rRETHROSCOPY 

''The  calculus  was  grasp.ed  and  broken  up  with  an  endovesical  forceps.  I  have  the 
fragments  in  my  surgical  collection.  I  curetted  the  mucosa,  completely  extirpating  all  the 
embedded  fragments  with  a  small  curette  that  could  easily  pass  through  the  cystoscopic  tube. 
The  small  vesical  wound  was  swabbed  with  3  per  cent  silver  nitrate  solution,  the  cystoscope 
withdrawn  and  the  bladder  irrigated  with  a  solution  of  protargol  1:1000,  using  a  large 
catheter.  The  irrigations  of  the  bladder  were  continued  for  several  days,  with  oxycyanide 
of   mercury    solution,    1:4000;    urotropin   internally. 

' '  The  after  effects  were  uneventful.  The  old  cystitis  improved  very  ^pitlly.  Cystos- 
copy was  repeated  twenty  days  later,  and  the  ulceration  caused  by  the  calculus  was  cicatrized. 
The  rest  of  the  mucosa  was  pale  and  in  fine  condition.  Microscopic  examination  of  the 
urine  showed  no  cocci  nor  leucocytes.  The  patient  was  then  referred  to  the  hydromineral 
station  at  Jesus,  near  Arequipa,  the  waters  of  which  are  specific  for  urinary  calculi.  The 
patient  returned  completely  cured. " 

Two  other  cases,  reported  by  Ferron,*  also  sliow  the  facility  with 
which  fragments  of  calculi  can  be  extracted  through  the  direct  vision 
cystoscope.  In  one  case  a  woman,  aged  fifty-seven  years,  in  the  service 
of  Pousson,  was  operated  upon  for  a  vesical  calculus  by  lithotrity.  The 
operation  was  done  without  undue  incident,  but  a  few  days  later,  she 
developed  a  rise  in  temperature,  the  bladder  became  painful  and  could 
not  tolerate  the  irrigations. 

Under  direct  vision  c^^stoscopy,  four  fragments  of  calculus  and  a 
large  quantity  of  inspissated  jdus  were  removed.  On  the  same  day  the 
temperature  droj)ped  to  normal  and  remained  so,  and  the  symptoms 
of  cystitis  rapidly  disappeared. 

The  second  case  is  that  of  a  man  sixty-eight  years  old,  with  nu- 
merous calculi  of  relatively  small  size.  Ferron,  using  the  direct  cysto- 
scope, removed  twenty-four  calculi  in  two  or  three  sittings;  the  two 
last  calculi  being  somewhat  larger,  necessitated  meatotomy. 

It  can  thus  be  seen  how  serviceable  this  method  really  is,  inasmuch 
as  it  made  iDOSsible  the  removal  of  a  calculus  of  V^-2  cm. 

Conclusion:  Considering  the  results  mentioned  in  the  jDreceding 
reports,  it  may  be  concluded  that  direct  vision  cystoscopy  is  distinctly 
indicated  in  all  cases  of  foreign  bodies  in  the  bladder  without  excep- 
tion, both  in  the  male,  as  well  as  in  the  female.  This  is  the  only  method 
which  makes  the  extraction  of  foreign  bodies  possible  under  the  most 
favorable  conditions  and  in  the  shortest  time. 

The  size  of  the  foreign  body  is  not  a  contraindication  against  this 
method,  because,  as  has  already  been  shown,  a  hairpin,  7^2  cm.  long, 
can  be  removed  by  this  method.  In  the  case  of  a  calculus,  preliminary 
crushing  will  enable  us  to  remove  all  the  fragments  without  overlook- 
ing any.  Finally,  this  method  conforms  with  that  principle  of  all  ra- 
tional surgery  which  demands  that  the  lesion  shall  be  seen  l)oth  before 
and  during  the  treatment. 


TltKAT-MKNT    OK    ('\S'|-1TIS  1371 


TiKrKItKXCKS 
iLuys:      MeilKiilc    ii:irli(iii('    d 'cxI  imt  iuii    ilcs   curiis   ol  iiiii^icrs   ilc    l;i    vcssic,    Lii   f 'liiii(|iic,    A|'ril 

1.1.  lonn. 

■  I'liliild  M.-iiliii:  I'n  ciis  (If  cystitc  (■liriiiiii|ii('  iiicnistiiiilc  ^^in'-iic  |i!ir  I ':iii|ilic;i(  ion  dircctc  ilc 
1  ii|]ii|ii('s  ;iu  iiKiyi'ii  ilu  cyst  i)sr(]|ic  i\f  I.iiys,  llitli  Scssiuii  of  the  Frciicli  rr<il(i;^ii-!il  Assn., 
Paris,   ()i-1(ilicr.    llMl',   p.    7(i;;. 

.■^Escdiiicl  :       La   ('lini.|u.',   October   ."I,   I'M:!,   No.  40,   p.   O.'U. 

•iFcnoii :      'i"liisis  of  .lanlon,  p.  ()5 ;  ulso  Calculs  vfvsiciiux  ot  CyHtoscopic  h  vision  ilirccif,  Jour. 

(1  'iii-oi.,  r.»i:;,  iii.  p.  :;i!». 


TREATMENT  OF  CYSTITIS 

At  ilio  present  da},  it  is  generally  admitted  lliat  iiiflaiiniiation  of 
the  N'csical  iimcosa  in  tlic  vast  iiia.jority  of  instances,  is  tlie  result  of  an 
iiillaiiiiiiatioii  of  sonic  ad.jacciit  ori;aii,  and  tliat  the  so-ealled  idio])atliic 
cystitis  does  not  exist  as  a  real  entity.  Xcvcrtiidcss,  tlic  painl'nl  >\nip- 
tonis  of  cystitis  constitute  a  ])at]i()lo*;ic  enscnihlc  wliidi  is  iin])ortant 
enough  to  demand  an  appropriate  local  therapy.  This  inqjortant  fact 
that  cystitis  is  a  secondary  lesion,  must  control  our  general  direction 
of  tlie  treatment  of  cystitis. 

It  is  therefore  essential  to  know  the  causes  which  underlie  the 
cystitis,  before  we  can  apply  the  treatment.  There  are  three  j^rinciijal 
causes:   Eenal,  inflammation  of  adjacent  organs  and  forei<;n  bodies. 

1.  Cases  of  Renal  Orig^.— This  is  the  most  frequent  cause  of 
cystitis.  In  these  cases  treatment  applied  to  the  bladder  will  never 
be  able  to  connteract  the  action  of  the  urine  which  is  continually  com- 
ing down  from  the  diseased  kidney,  loaded  witli  microbes  and  pus,  thus 
irritating  the  bladder  and  ])roducing  the  intlammation. 

2.  Inflammation  of  Adjacent  Organs. — In  the  male,  intiammation 
of  the  prostate  and  seminal  vesicles  is  one  of  the  most  frequent  causes 
of  cystitis.  In  the  female,  gonorrheal  and  tuberculous  intlannnation  of 
the  nterns,  tubes,  and  adnexa,  is  one  of  the  most  common  causes. 

But  the  organs  in  the  immediate  vicinity  of  the  bladder  are  not  the 
only  canses  of  cystitis.  Pelvic  abscess  may  attack  the  bladder:  a 
pnrulent  collection  in  the  appendix  may  perforate  the  l)ladder ;  a  can- 
cel- of  the  rectum  or  of  the  vagina  or  a  cold  abscc^ss  of  the  vert(0)ral 
column  may  rupture  into  the  bladder. 

8.  Foreign  Bodies. — h'oi-eign  bodies  remaining  in  the  bladdci'  for 
some  length  of  time,  w  ill  ])roduce  inllannnation,  whether  they  he  endo- 
genous, like  calculi,  or  exogenous,  of  infinite  variety   (see  page  357). 

The  diagnosis  of  cystitis  can  really  be  made  oidy  through  cystos- 
c()])y,  much  beiler  lliaii  through  the  thi'ec  cardinal  syniptums  of  c\-('ry 
classic  textbook,  namely,  pain,  tVe(|uency,  and  ])yuria. 


372  CYSTOSCOPY   AND   URETHROSCOPY 

In  cystitis,  indirect  cystoscopy  is  markedly  inferior  to  tlie  direct 
method.  First,  because  the  affected  bladder  will  not  tolerate  a  proper 
distention  by  the  flnid,  owing  to  the  painful  contraction  of  the  walls 
and  the  hemorrhage  which  it  produces.  A  bladder  Avitli  cystitis  is 
very  sensitive  to  the  slightest  contact;  indirect  cystoscopy  is  therefore 
uncomfortable  both  for  the  patient  and  the  surgeon. 

Another  disadvantage  is  found  in  the  fact,  already  mentioned 
above,  that  it  is  impossible  to  apply  apj)ropriate  local  treatment  at 
will,  even  though  the  lesions  have  been  distinctly  isolated. 

Direct  vision  cystoscopy  eliminates  all  these  disadvantages  and 
gives  the  best  results.  In  the  first  jilace,  there  is  no  minimal  vesical 
capacity  for  my  direct  vision  cystoscope;  the  bladder  dilates  normally, 
without  being  forced,  and  consequently  without  pain.  Usually  pain 
is  felt  only  when  the  tube  enters  tlie  bladder,  owing  to  the  inflammation 
of  the  vesical  neck.  This  little  disadvantage  can  be  easily  overcome  by 
the  employment  of  local  stovaine  anesthesia.  But  once  the  instrument 
has  entered  the  bladder,  the  best  results  can  be  obtained. 

It  goes  without  saying,  that  in  cystitis  as  in  urethritis,  it  is  highly 
inadvisable  to  apply  local  treatment  to  the  mucosa  as  long  as  it  is  acute- 
ly inflamed;  when  this  condition  has  receded  through  the  use  of  proper 
medication,  the  direct  vision  cystoscope  can  be  used  with  telling  re- 
sults. In  these  circumstances,  cystoscopy  shows  tliat  the  mucosa  is 
inflamed  in  certain  spots,  while  the  rest  of  the  bladder  is  normal  and 
devoid  of  any  lesion;  red  and  bloody  patches  of  severe  cystitis  can  be 
seen  adjoining  the  pinkish  white  health}^  mucosa.  It  may  thus  be  seen 
how  irrational  it  is  to  apply  active  medicinal  substances  to  the  healthy 
mucosa  as  well  as  to  the  diseased  parts  simultaneously.  The  rational 
method  is  to  treat  the  diseased  areas  vigorously  and  actively,  omitting 
the  healthy  portions.  This  can  be  accomplislied  by  the  use  of  the  di- 
rect vision  cystoscope,  through  which  it  is  possible  to  treat'  the  dis- 
eased portions  by  the  cautery  or  the  silver  stick,  while  the  healthy 
parts  are  not  interfered  with  at  all. 

Operative  Technic  in  the  Treatment  of  Localized  Cystitis 

The  operative  technic  of  the  treatment  of  cystitis  with  the  direct 
vision  cystoscope  is  the  same  as  that  used  in  direct  vision  cystoscopy 
in  general.  The  entire  mucosa  having  been  examined  and  the  lesions 
localized,  the  end  of  the  tube  is  brought  directly  in  contact  with  them. 
The  mucosa  is  then  cleaned  with  a  swab  of  sterile  cotton,  in  order  to 
obtain  a  more  intense  action  of  the  drug  to  be  employed.  The  mucosa 
Jiaving  thus  been  dried,  concentrated  solutions  appropriate  to  each  par- 
ticular case,  are  then  used. 


TIM:AT.M  KXT    OK    ('-/S'l'ITIS  6(6 

Til  ^oiion'lic.'il  cNstilis  xciy  iiiai'ki'd  I'csults  ai'c  ()l)laiiie(l  by  the  use 
of  local  ap|)li('alioiis  of  7)  lo  10  j)(>|-  ceiil  siKci-  iiid'ale  sohilioii;  occa- 
sioiiall>'  the  pure  siKcr  slick  iiia>'  lie  iisc(|  with  .^ucccss.  In  tlif  roi'iii  of 
clii-oiiic  cystitis  wliicli  is  riiMnicnl  l\-  ()1is('I\(mI  in  woincii,  due  lo  a  liii;li 
(l('_Ui-('('  of  POiU'Oiitration  of  llic  iiiiiic,  the  lesions  are  locaiiziMl;  tiiey  ai'e 
well  shown  in  Phite  XII,  Fii;-.  .'!.  In  these  cases,  the  silver  applied  lo- 
call\'  to  the  alTeclcd  parts,  ,i;-i\('s  alisolutely  reniai'kahle  i-esulls. 

I  iinnnieialile  cases  liaxc  lieen  repor1e(|  with  the  most  con('ln>i\('  re- 
sults. When  a  cxstitis  has  had  a  lon^'  duration,  or  when  the  extremely 
thickened  mucosa  presents  indurated  ai'eas  at  certain  ])oints  of  its  sur- 
face, it  ma\'  he  mistaken  I'oi'  a  neoplastic  piolileration.  In  these  con- 
ditions, 10,  20,  or  e\-eii  .^O  pei"  ceid  soluli(Mis  of  resoi-cin  may  ])e  used 
witii  <;•  ratifying;'  results.  It  ^oes  without  sayini;',  of  coui-se,  that  much 
care  must  he  taken  in  the  use  of  such  couceidrated  a])])licatioHs,  lest 
they  s])i'ead  to  the  suri'oundin,'^-  liealths'  tissuc^s.  To  j)revent  this  pos- 
sible spreadin*;'  of  the  solution,  it  is  safe)'  to  di-\'  the  mucosa  aftei'  the 
application  of  the  caustic  has  l)een  made. 


Sfflte 


Fig.   217. — Silver   nitrate   stick   for  endovesical   cauterization. 

In  some  instances,  the  galvanocautery  may  be  used,  Imt  its  appli- 
cation must  be  extremely  superficial,  and  made  very  gently.  I  nder 
these  precautions  they  are  both  painless  and  effective. 

Eeports  of  cases  of  cystitis  cured  witli  the  direct  vision  cystoscope 
are  innumerable;  only  a  few  will  be  mentioned  here. 

In  one  instance  a  cystitis  developed  subsequent  to  the  ojx'iiing  of 
an  abscess  near  by;  it  was  Avonderfully  improved  l)y  the  application  of 
silver  nitrate  to  the  affected  surface.  Only  a  few  ai^plications  were 
I'ecpiired  to  produce  this  excellent  result. 

In  a  second  case  of  cystitis,  due  to  perforation  into  the  bladder  of 
an  abscess  secondary  to  Pott's  disease,  local  treatment  with  the  cysto- 
scope gave  a  most  happy  result. 

In  tuberculous  cystitis  whicli  is  usually  so  rebellious  to  treatment. 
direct  view  cystosco])y  can  be  of  luirticulai  \alue.  In  the  vast  majority 
of  cases,  this  tuberculous  cystitis  is  secondary  to  a  tuberculous  inllam- 
mation   in   the  corres])oiidiiig  kidney;  the  real   tretdment  of  unilateral 


374  CYSTOSCOPY    AXD    URETHEOSCOPY 

renal  pyoneplirosis  is  of  course,  nephrectomy.  Nevertheless,  very 
painful  symptoms  of  cystitis  jDersist  as  a  rule,  long  after  this  operation, 
and  in  such  cases  direct  vision  cystoscopy  gives  most  splendid  results. 

Ax)plications  of  tincture  of  iodine,  silver  nitrate,  concentrated  so- 
lutions of  lactic  acid,  or  the  actual  cautery,  are  usually  painless  and 
liighly  effex?tive.  ^^ 

Ferron  Ims  published'  reports  of  two  interesting  cases,  on  this  sub- 
ject. 

Case  43. — ^A  woman,  aged  twenty-six  years,  had  a  right  nephrectomy  performed  on 
July  17,  1909.  After  the  operation,  although  her  physical  condition  was  good,  she  still 
complained  of  resical  sj-mptoms.  Local  treatment  with  the  direct  cystoscope  gave  m-ost 
excellent  results  in  a  short  time. 

Case  41. — This  case  is  very  conclusive.  A  woman,  aged  thirty-three  years,  was  nephrec- 
tomized  for  a  left  renal  tuberculosis,  on  August  2,  1910.  After  the  operation,  she  still  had 
symptoms  of  tuberculous  cystitis;  tliis  condition  was  treated  according  to  Luys'  method. 
The  improvement  was  rapid  and  a  gniinea-pig  inoculation  in  1910  was  negative.  Before  the 
treatment,  the  patient  had  voided  every  five  minutes  by  day,  and  had  incontinence  by  night; 
after  treatment  diurnal  micturition  became  normal,  and  there  was  no  call  to  void  at  night.  Her 
vesical  complaint  was  perfectly  cured. 

Paul  Jardon  has  stated"  that  direct  vision  cystoscoj)}--  is  indicated 
in  all  cases  of  cystitis;  it  assures  a  thorough  examination  of  the  blad- 
der and  makes  possible  a  rational  treatment  of  the  lesions. 

KEFEREI^rCES 

iFerron:     Du  fouctionnement  du  rein  restant  ajjres  nephrectomic,  Bordeaux,  1910. 
2Jardon:     Be  la  cystoscopie  a  vision  directe,  Bordeaux,  1912,  pp.  44  and  45. 


INSTRUMENTAL  EXPLORATION  OF  THE  INFERIOR 
EXTREMITY  OF  THE  URETER 

Thanks  to  the  cystoscope,  the  inferior  end  of  the  ureter  can  be 
examined  in  the  same  manner  as  Ave  examine  the  urethra.  For  this 
purpose  Kelly^  used  a  slightly  curved  blunt  probe  which  he  called  a 
"searcher."  Jeanbrau  utilizes  a  metallic  explorer  with  a  flexible 
shaft  for  extraperitoneal  ureterolithotomy.  Ferron^  also  uses  metallic 
instruments  consisting  of  a  flexible  shaft  ending  in  a  No.  7  or  8  bulb, 
and  similar  to  Guy  on 's  ureteral  explorers.  Pasteau  has  constructed 
ureteral  explorers  of  rubber,  similar  to  Guyon's  instruments. 

The  caliber  and  condition  of  the  ureter  can  be  ascertained  with 
any  of  these  instruments.  The  technic  is  the  same  as  that  in  urethral 
exploration.  When  the  instrument  is  arrested  at  a  given  point,  it  is  an 
indication  of  the  presence  of  an  obliteration,  a  Ivink,  a  tight  stricture, 
or  a  calculus.    When,  on  the  other  hand,  a  fine  instrument  passes  be- 


EXPLORVTfON'    OF    THE    UPiETEH  O  <  0 

yoiul  an  obstriu-tioii  l)ul  ])roseiits  a  sudden  i-elaxalion  and  free  move- 
ment on  being  Avitlidrawn,  a  .stricture  may  be  taken  for  granted. 

This  method  of  examination  is  also  occasionally  employed  for  the 
extraction  of  a  calculus  or  a  foreign  body  from  the  ureter.  I  have  tried 
dilatation  of  the  ureter  in  a  woman  with  a  ureteral  calculus,  in  Pozzi's 
service.  I  introduced  a  bougie  into  the  ureteral  orilice  and  left  it  in 
place  for  twentj^-four  hours,  to  bring  about  dilatation.  The  attempt 
was  unsuccessful,  because  the  calculus  was  embedded  in  and  adherent 
to  the  mucosa,  and  could  not  be  moved.  It  was  subsequently  ex- 
tracted through  a  subperitoneal  laparotomy. 

Other  foreign  bodies  can  likewise  be  extracted  froin  the  ureter  ])y 
means  of  a  fine  forceps.  Thus,  I  was  once  called  u])Oii  to  extract  a  ure- 
teral catheter  from  the  bladder,  in  one  of  the  largest  surgical  services 
in  Paris.  During  the  course  of  an  exploratory  laparotomy,  conti-ary 
to  all  expectation,  a  large  calculus  was  discovered  in  the  right  ureter. 
The  calculus  was  removed,  the  ureteral  wall  sutured  and  a  catheter 
introduced  into  the  lower  end  of  the  ureter  for  urinary  drainage.  The 
catheter  was  deemed  long  enough  to  extend  into  the  interior  of  the 
bladder. 

I  was  therefore  called  upon,  several  days  after  the  opei-ation,  to 
remove  the  catheter,  which  was  thought  to  be  in  the  bladder.  To  my 
surprise,  I  found  the  bladder  absolutely  empty,  without  any  trace  of 
a  ureteral  catheter.  But  the  ureteral  orifice  -was  extremely  puffy.  A 
small  forceps  w^as  introduced  into  the  ureter,  but  nothing  w^as  felt.  It 
was  then  believed  that  the  catheter  had  remained  in  the  ureter  and 
had  not  descended  into  the  bladder.  Another  operation  was  there- 
fore subsequently  performed;  the  lower  extremity  of  the  kidney  was 
exposed  and  the  pelvis  incised.  The  catheter  w^as  found  at  the  upper 
end  of  the  ureter.  It  was  immediately  removed,  and  the  patient  made 
an  uneventful  and  perfect  recovery. 

Apart  from  the  exxDloration  of  the  ureter  per  se,  another  indica- 
tion for  ureteral  catheterization,  of  the  greatest  importance,  is  the  in- 
sertion of  a  catheter  into  the  ureter,  before  operating  upon  the  ureter 
or  upon  one  of  the  adjacent  organs,  so  as  to  be  able  to  identify  and 
protect  the  ureter. 

Endoscopic  uretero -vesical  7neatotomy  for  the  removal  of  a  cal- 
culus from  the  ureter  in  a  female,  was  reported  by  Gauthier,  of  Lyons,' 
as  follows : 

"C,  aged  tliirty- seven  years,  entered  the  Hotel-Dieu  Hospital  of  Lyons,  on  April  20, 
1912,  in  the  service  of  my  teacher  and  friend.  Tixier,  for  chronic  and  persistent  nephritic 
colic.     No  hereditary  urinary  history;  father  died  of  pulmonary  tuberculosis. 

"Personal  history:     It  seems  that   about  ten  years  ago,  she  suffered  from   a   gastric 


376  CYSTOSCOPY  AjStd  urethroscopy 

ulcer,  for  about  three  or  four  years.  This  was  sul;sequently  cured.  For  the  past  three  years, 
she  has  complahied  of  pains  in  the  left  lumbar  and  right  iliac  regions.  The  lumbar  pains 
are  the  more  severe ;  these  are  real  attacks  of  renal  colic,  occasionally  lasting  twelve  hours 
and  coming  on  almost  at  weeldy  intervals  during  recent  months.  The  pains  in  the  right 
side  are  continuous,  with  exacerbations  from  time  to  time.  During  these  crises  they  radiate 
toward  the  corresponding  thigh,  which  appears  as  if  paralyzed  for  the  time  being.  During 
these  iliolumbar  attacks,  she  also  complains  of  vesical  symptoms ;  i.  e.,  increased  frequency 
and  cystalgia.     When  the  crises  have  subsided,  the  bladder  is  quite  normal. 

' '  She  never  passed  any  calculi  or  gravel.  At  the  beginning  of  her  illness  she  had  a 
few  attacks  of  hematuria,  but  it  is  difficult  to  determine  their  character.  Tire  patient  has 
lost   much   flesh   and  strength;    her   a^Dpetite  is   poor. 

"Examination:  General  condition  fair;  no  fever;  lungs  and  heart  normal.  The  urine 
is  not  clear,  and  coirtains  leucocytes,  urinary  eisithelium,  and  a  few  red  blood  cells.  A  large 
albumin  ring  is  out  of  all  proportion  to  the  xjyuria.  Palpation  of  the  kidneys  and  ureters, 
reveals  the  following  painful  areas:  On  the  right  side,  costolumbar  and  upi)er  middle  ure- 
teral ;  on  the  left  side,  the  costolumbar  and  middle  ureteral.  The  inferior  pole  of  the  right 
kidney   is  palpable   and   sensitive;    the  left  kidney   can  not   be   felt. 

' '  Vaginal  examination  reveals  a  metritis  of  the  neck  and  a  moderate  vesical  prolapse. 
A  hard  mass  is  felt  distinctly  in  the  left  lateral  vaginal  cul-de-sac.  This  mass  is  about  the 
size  of  a  small  kidney  bean,  and  is  continued  upward  and  outward  by  a  thick  elastic  and 
resistant  cord,  haviirg  the  caliber  of  a  No.  IS  rubber  catheter. 

"It  is  evident  that  this  cord  is  the  ureter  and  that  the  hard  mass  is  a  calculus  embedded 
in  tins  canal.  The  diagnosis  seems  to  be  quite  certain  according  to  the  examination.  Tliis 
is  a  case  of  double  renoureteral  lithiasis.  Eadiography  of  the  entire  urinary  tract  shows  a 
localized  lithiasis  of  tha  right  kidney  and  left  ureter.  There  are  no  stones  in  the  left  kidney 
or  the  right  ureter.  In  the  right  kidney,  a  large  shadow  is  clearly  seen,  the  size  of  an  ordi- 
nary plum.  Three  distinct  shadows  are  seen  in  the  left  ureter.  The  lowest  corresponds 
exactly  in  size  with  the  kidney  bean  f ourrd  on  vaginal  examination ;  the  others  are  about 
half  its  size.  Cystoscopy  showed  a  normal  bladder.  The  left  ureteral  orifice,  though  slightly 
red,  is  not  larger  than  the  right.     The  ureters  were  not  catheterized. 

"We  decided  to  attack  the  right  kidney  first,  rejecting  external  ureterotomy  at  once. 
Operation,  May  6,  1912  (Tixier).  The  calculus  is  distinctly  felt  in  the  renal  pelvis,  and  is 
removed  by  pyelotomy,  notwithstanding  its  large  size.  It  weighs  16  gms.,  and  is  uratic 
in  appearance. 

"The  results  of  the  operation  are  excellent;  no  fever,  maximum  temperature  being 
100.6°  F.    Urinary  escape  ceased  in  eight  days,  and  total  closure  of  the  wound  in  fifteen  days. 

"On  the  eleventh  day,  violent  nephritic  colic,  with  temperature  of  104°  F.  aird  oliguria. 
For  four  days  the  temperature  varied  between  102.2°  and  10-t°.  Sharp  lumboiliac  pains, 
scanty  urine;  then  sudden  defervescence  and  disappearance  of  the  pains  and  increase  in  the 
ciuantity  of  urine  passed. 

"After  48  hours  of  normal  temperature,  left  ureteral  catheterization  (on  May  22),  in 
order  to  ascertain  the  exact  position  of  the  lower  ureteral  stone.  We  attempted  to  remove 
it  through  the  natural  channels.  An  obstacle  is  encountered  about  4  cm.  from  the  uretero- 
vesical orifice.  A  No.  13  catheter  is  introduced  to  a  distance  of  15  cm.  About  250  e.c.  of 
cloudy  renal  urine  are  thus  evacuated.  The  urine  contains  a  few  leucocytes,  many  crystals 
and  a  little  albumin.  The  high  fever  coincident  with  the  attack  of  left  renal  colic  can  not 
be  explained  by  the  retention  of  the  septic  urine.  The  urine  retained  in  the  kidney  can  not 
be  considered  purulent  because  it  contained  but   a  few  leucocytes. 

"On  May  23,  two  days  after  the  catheterization,  instead  of  the  improvement  we  ex- 
pected, the  colic  aird  temperature  (102.2°  F.)  reappear.  Radical  operation  is  decided  upon. 
Before  the  external  ureterotomy,  we  will  attempt  removal  of  the  large  lower  stone  through  the 
natural  channels.  Transverse  splitting  of  the  orifice  and  the  ureter  will  be  tried  endo- 
scopically.  Tliis  will  be  follow^ed  by  combined  traction  through  the  bladder  and  rectum,  to 
bring  the  calculus  into   the  bladder. 


KXI'I.OKATIOX    Ol'    'I'lIK    lltliTKJ;  .]  i  ( 

''AFjiy  1^."),  ("iiiliisc()|iic  operation  ((Jaiitliicr).  F'ationt  is  phicpil  in  the  inclined  posi- 
tion Mini  ctiici  i/.cil.  'I'll.'  uictiira  is  dilated  and  Luys'  evstosfopo.  nieasurintr  14  mm.  in 
diameter  is  introduced,  'llw  loft  ureteral  orifice  is  seen  readilv.  This  is  catheterizod  with 
a  rulilier  conductor,  No.  4  Charriere  and  Maisonneuve,  5  cm.  in  len^^th,  screweil  upon  a 
straight  tmmeled  metallic  Maisonneuve  conductor.  Tiie  entire  ruldier  conductor  (carrier) 
is  inserted  into  the  mctci-,  between  the  ureteral  wall  and  the  stone.  Alioiit  .'I  cm.  of  the 
metallic  conductor  is  passed  into  the  nii'teriil  orifice.  .\  Maisonneuve  No.  2  knife  is  1  hr-n 
en<^a>^ed  in  tin'  -roo\c  of  ihr  conductor  and  advanced  toward  the  meatus.  The  orifice  is 
then  split  umler  the  control  of  the  eye;  nothing;-  lias  been  done  in  the  dark,  thanks  to  the 
larjje  lumen  of  tiie  cysto.scopic  tiilie.  The  Made  is  advaii<-ed  until  its  summit  ilisajipears 
in  the  vesical   mucosa.     I[emoi'rlia;;e   is  moileiale. 

".Ml  the  instiiinients  are  now  rem<i\-ed  from  the  lilaihler.  The  urethra  is  dihilerl  up 
to  IS  French.  The  left  index  finoer  is  introduc<'d  into  the  bladder,  llie  iij;ht  into  the  redtini. 
Both  hiijrers  fee!  the  stone  distinctly  {jiaspinti  it  and  (b-awin<;-  it  into  the  bladder,  whence 
it  is  extracted.  The  operation  is  OJided  ;  it  has  lasted  about  tifteen  minutes.  'Hie  calculus, 
has  the  shape  of  a  date  seed,  aiid  wei<;hs  0.80  om. 

"On  the  followiii-  day,  a  second  stone,  wei;:hin-  0.35  uni.  is  spontaneously  eliminated. 
On  the  third  day,  a  third  stone  is  passed,  weighing  O.l.j  gm.  Thus  the  patient  is  made  rid  of 
1h(^   threc^   stones  reveah>d  by   the  x-ray. 

"IVrmauent  apyrexia  is  attained  on  the  eighth  day.  The  quantity  of  urine  increased 
enormously  after  the  relief  of  the  left  kidney.  She  passed  from  200  to  400  c.c.  on  Mav  29, 
and  more  than  two  liters  during  an  entire  week. 

■'On  June  8,  albuminuria  disappeared.  On  tlie  same  day  it  was  found  that  the  length 
of  the  left  ureteral  orifiec  is  five  to  six  mm.  Xo  definite  trace  of  the  incision  can  be  seen. 
The  bladder  is  normal,  not  inflamed.  A  catheter  Xo.  14,  penetrates  the  left  ureter  easily, 
for  about  25  cm.  There  is  no  pyelitic  residuum.  The  pelvic  capacity  is  45  c.c.  The  patient 
left  tlie  hospital  in  perfect  condition. 

"On  August  24  she  was  seen  again.  She  complained  of  left  lumliar  pain  principally 
at  night.  There  is  a  certain  relationship  between  these  pains  and  her  digestion.  The  pains 
are  diminished  perceptibly  on  a  restricted  diet.  She  al.so  has  acid  eructations  and  epigastric 
inflation  after  meals  and  frequent  headaches. 

"Tlie  general  condition  is  improved;  she  has  gained  thirteen  pounds  since  leaving  the 
hospital.  The  urine  is  clear;  no  ;illmmiii.  Palpation  of  the  kidneys  and  ureters  is  not  pain- 
ful. Left  catheterization  is  negative.  Appropriate  diet  is  prescribed  for  the  dyspeptic 
trouble. 

"  Sei)temljer  27,  the  jiatient  writes  that  her  left  lumber  pains  have  nearly  disappeared 
under  the  regulation  of  diet. ' ' 

Conclusions. — Ureteral  stricture  often  obstructs  tlie  passage  of  a 
ureteral  stone.  AVhen  the  calculus  can  be  moved,  ureterotomy  is  indi- 
cated. Tliis  is  easily  done  in  women  tbrou.iili  the  natni-al  channel.^, 
using  Maisonneuve 's  straight  urethrotome,  introduced  through  Luys' 
14  nmi.  cystoscope.  Tlie  operation  must  ])e  done  cautiously,  avoiding 
the  periureteial  venous  plexus;  it  is  also  impei-ative  to  avoid  cutting 
the  bladder  proper.  If  tliis  inctliod  fails,  external  iirelerotoniy  can  al- 
ways be  I'esorted  to. 

Ferron  also  has  reported  an  interesting  case,  which  shows  the  con- 
siderable value  of  dilatation  of  the  inferior  extremity  of  the  ureter  for 
tlie  establisliiiiciii  oi'  tlic  IVcc  ui-in;ir_\-  How  IVom  llic  k-iijncy.' 

"A   girl   aged   eighteen   years,   suffering   from    gonorrheal   cystitis,   cimiplained   of   pain 


378  CYSTOSCOPY   AXD    TEETHEOSCOPY 

in  the  lumbar  region.  Bimanual  examination  revealed  pain  on  the  right  side,  although  the 
kidney  was  not  perceptible.  The  cystitis  was  treated  locally  through  Luys"  cystoseope  and 
improved  I'apidly. 

"Examination  of  the  ureteral  orifices  then  became  possible.  The  left  orifice  was  found 
noi-mal,  but  the  right  orifice  was  the  size  of  a  pin  point,  and  too  small  to  permit  the  en- 
trance of  the  smallest  catheter.  The  ureteral  ejaculation  on  this  side  occurred  in  the  form 
of  a  filiform-sized  jet. 

'  •  The  extremity  of  the  cystoscopic  tube  in  contact  with  the  neck,  we  wei^  enalded  to 
demonstrate  to  the  gathered  students  of  the  service,  that  a  filiform  jet  of  urine,  emerging 
from  this  orifice,  shot  across  the  cystoscopic  field  and  struck  the  anterior  wall  of  the  blad- 
der, although  the  viscus  was  distended  with  air.  This  orifice  was  dilated  with  filiform 
bougies,  in  a  few  sittings.  Catheterization  became  easy,  and  the  two  hour  test  revealed  a 
normal  kidney.  The  patient  was  kept  under  regular  obseiwation  but  never  complained  again. 
We  believe  her  former  pains  were  due  to  the  ureteral  stricture. ' ' 

Bransford  Lewis^  also  favors  the  extraction  of  ureteral  ealciili 
tlirongli  tlie  natural  channels.  He  either  dilates  the  ureteral  orifice  or 
he  grasps  the  calculus  with  a  crocodile  forceps  fitted  upon  a  flexible 
liandle.  He  introduces  it  into  the  ureter,  advances  it  up  to  the  calcu- 
lus, grasps  it  and  gently  Y\ut]idraAvs  it.  He  tlius  removes  ureteral  cal- 
culi even  in  the  male. 

[The  editor^  reported  a  case  of  calculus  impacted  in  the  ureteral 
orifice  in  a  young  man.  Indirect  cystoscopy  shoAved  a  jagged  point  of 
the  stone  jDrojecting  beyond  the  ureteral  orifice  into  llie  bladder,  but 
held  tightly.  H  was  seized  by  an  oi^erating  forceps,  and  though  the 
projecting  tip  broke,  the  remainder  of  the  calculus  was  grasped  Avithin 
tlie  lumen  of  the  ureter,  at  the  same  sitting,  and  witlidi'aAvn  from  the 
bladder.    There  has  been  no  recurrence  since  then. — Editor.] 

EEFEEEXCES 

iKelly:     Am.  Jour.  Obst.,  1895,  p.  12. 

2Ferron:     Jour.  d'uroL,  December,  1912. 

sG-authier:     Assn.  franc,  d'urol.,  191o,  p.  Q-iiQ. 

•iFerron:     Jour,  d'urol.,  1913,  iii,  65. 

sLewis:     Xew  York  Med.  Jour.,  Xov.  15.  1912.  p.  1002. 

eWolbarst:     Urol,  and  Cut.  Eev..  .January,  1915,  xix,  Xo.  1. 

VESICAL  BIOPSY 

Histologic  examination  of  fresh  specimens  of  vesical  tuiiior-^  is  of 
great  imiDortance  in  making  a  diagnosis;  this  desideratum  is  realized 
in  a  very  simple  and  perfect  manner  Avith  my  direct  Ausion  cystoseope. 

In  tAvo  cases,  this  procedure  lias  given  me  signal  results.  A 
Avoman,  aged  sixty-tAvo  years,  Avhom  I  nephreetomized  for  left  renal 
tuberculosis  tAvo  years  preA'iously,  came  to  me  Avith  hematuria.  Cysto- 
scopic examination  of  the  bladder  shoAved  a  number  of  budding  masses. 


VESICAL,   BIOPSY  379 

Considering'  the  age  ol.'  the  ])atient,  th(\<e  bodies  mi^^ld  have  Ijeen  con- 
sidered epithelioniatons  in  cliaraetei-. 

Histologic  exainiiialioii  of  fi'ag'iiieiits  reiiiove(l  thi-()UL;'li  tlie  cysto- 
scope,  revealed  only  sini])le  intiannnatoi-y  nodules,  due  to  a  concen- 
trated tuberculous  cystitis.  Local  apijli^^dioiis  of  a  concentrated  solu- 
tion of  lactic  acid  were  followed  by  excelh'iit  and  rajjid  results. 

Anothei-  cas(\  a  man,  aged  sixty-five  years,  presented  a  small  tu- 
mor on  the  left  lateral  wall  of  the  Idadder  Ix'hind  the  ureteral  orifice. 
Microscopic  examination  of  a  fragment  oL'  tissue  revealed  a  vesical 
epithelioma.  The  history  of  this  case  is  reported  in  detail  in  connec- 
tion with  the  application  of  radium  in  vesical  tumors  (page  355). 

Vesical  biopsy  should  be  resorted  to  as  often  as  possible,  for  the 
establishment  of  a  correct  diagnosis;  its  splendid  results  can  ])e  l)est 
appreciated  by  anyone  using  the  direct  vision  cystoscope  for  this 
purpose. 


INDEX 


A 

Al^scess,  jieriurctlual,  1)8 
Adrenalin,  in  uiPthroscopy.  SI 
Alypin,  in  uietliral  spasm,  190 

in    urethroscopy.    77 
Anatomic  considerations  of  )>la(l(l(M-, 
Anomalies  of  bladder.  206 
Appendicitis,  cystoscopy  in,   144 
Aspiration   of  urine,   223 

B 

Binocular  vision,  178 
Biopsy,  vesical,  378 
Bladder : 

anatomic  considerations^  147 

anomalies,   206 

biopsy,  378 

calculus,  164,  284,  364 

cancer,  163.  208,  300,  355 

capacity  for  cystoscopy,  190 

deformity  in  pregnancy,  248 

diverticulum,  206 

fistula,  336 

foreign  bodies,  357 

herpes,  228 

in  indirect  cystoscojDy,  198 

leucoplakia,  204,  240 

neck,  176,  202,  310 

abscess  of,  310 

polypi  on,  270 
normal  mucosa,  149,  198 
papilloma,  160,  163,  176,  202,  338 
pathologic  mucosa,  199 
perforation,  142,  176,  236 
lahotography,  179 
silk  thread  in,  188 
syphilis  of,  188 
trabeculated,  214 
tumors,  205,  329,  358 

differential  diagnosis,  206 

electrocoagulation  in,  347 

electrolysis  in,  354 

galvanocautery  in,  330 

radium  in,  355 

snare  in,  342 

treatment  of,  329 
urine,  aspiration  of,  223 
varix,  164,  207 
Bullous  edema,  204,  209,  322,  358 

C 

Calculus,  ureteral,  307,  311 
vesical,  164,  284,  364 


147 


Cancel',  uterine,  211 

vesical,  163,  208,  300,  364 
Capacity  of  Ijladder,  190 

of  renal  pelvis,  210 
Casts,  vesicular,  123 
Cathetci',  ureteral,  262 
radiography  of,  326 
infection  by,  293 

wax-tipped,  308 
Catheterization  : 

of  ejaculatojy  ducts,  115 

ureteral,  210,'  254 
a  demeure,   324 
dangers  of,  291 
errors  in,  298 
in  childien,  306 
indications  for,   307 
Kelly's  method,  267 
Luys'  method,  269 
Central  figure  in  hard  infiltration,  91 

in  soft  infiltration,  90 

in  urethroscopy,  82 
Children,  cystoscopy  in,  193 
Colic,  renal,  312 

Contraindications  to  urethroscojiy,  81 
Cystic  urethral  glands,  97 
Cystitis : 

acute,  199 

chronic,  200 

follicular,  203 

gonorrheal,  203 

granular,  203 

parenchymatous,  201 

treatment  of,  371 

tuberculous,  203 

villous,   201 
Cystoscopes  (types)  : 

Albarran,  256 

Baer,  180,  261 

Bierhoff,  259 

Brenner,  254 

Brown,  255 

Casper,  256 

Cullen,   60 

Delbet,  61 

Fenwiek,  175 

Frank,  260 

Freudenberg,  260 

Garceau,  58 

Guterbock,  175 

Hogge,  59 

Israel,  259 

Janet,  61 

Kelly,  57 

Kollmann,  180 

Luys,  61,  224,  333 


581 


382 


Il^DEX 


Cystoscopes — Cont  'd. 
Nitze,  168,  255 
Pawlick,  58 
Rocher,  175 
ScMagiutweit,    177 
Wossidlo,  260 
Cystoscopy,  139 
bladder  in,  147 
bladder  capacity  for,  190 
dangers  of,  165 
direct  vision,  56,  218,  245 

advantages  of,  234 

during  pregnancy,  248 

objections  to,  242 
errors  in,  162 
history  of,  54 
in  appendicitis,  144 
in  bladder  cancer,  208 
in  bladder  tumors,  205,  241 
in  children,  193 
in  cystitis,  199,  228,  240 
in  diverticulum,  193,  206 
in  female,   193 

in  perforation  of  bladder,  142 
in  pregnancy,  241,  248 
in  prostatic  hypertrophy,  141 
in  utei'ine  cancer,  207,  211 
photographic,   179 
prismatic,  168 
indirect  vision,  168 

advantages  of,  194 

diflficulties  of,  ]89 

disadvantages  of,  194 

technic  of,  181 

technie  of,  ISl 
Cystotomy,  suprapubic,  329 


D 


Dangers  of  cystoscopy,  165 
Differential  diagnosis  of  bladder  tumors,  206 
Difficulties  of  indirect  cystoscopy,  189 
Direct  vision  cystoscopy,  56,  218,  245 

advantages  of,  234 

objections  to,  242 
Disadvantages  of  indirect  cystoscopy,  194 
Diveiticulum  of  bladder,  206 


E 


Edema,  bullous,  204,  209,  322,  358 
Ejaculation,  ureteral,  158,  176 
Ejaculatory  ducts,  101,  104 

catheterization  of,  115 

stricture  of,  128 
Electrocoagulation,  of  bladder  tumors,  347 
Electrolysis,  in  bladder  tumors,  354 
Endoscoi^y  (see  Urethroscopy) 

history  of,  25 
Endourethral    treatment    of    prostatic   liyper- 

trophy,  135 
Endovesical  treatment  of  bladder  tumors,  330 
Errors  in  cystoscopy,  162 

in  ureteral  catheterization,  298 


Female,  cystoscopy  in  the,  193 
Female  urethra,  112 

urethroscopy  in  the,  110 
Fistula : 

urethrovesicovaginal,  214,  236 

vaginal,  236 

vesical,  336 

vesicovaginal,  237 
Follicular  prostatitis,  101  **■ 

urethritis,   96 
Foreign  bodies  in  bladder,  357 

G 

Galvanocauterization  in  bladder  tumors,  330 
Glands,  Littre's,  84,  95,  132,  146 
cystic,  97 

H 

Hard  infiltration,  88,  91 

central  figure  in,  94 

Oberlaender 's  classification,  93 

posterior  urethra  in,  106 
Hematuria,  235 
Herpes  vesicalis,  228 
Hvdronephrosis,  278 
Hypertrophy  of  the  prostate: 

cystoscopy  in,  141 

endourethral  treatment  in,  135 

urethroscopy  in,  109 


Indigo  carmine  test,  159 
Indirect  cystoscopy,  168 
Infection  by  ureteral  catheter,  293 
Infiltration,  urethral : 

hard,  91 

soft,  89 
Injection  into  seminal  vesicles,  129 


Lacuna?  of  Morgagni,  84,  95,  146 

obliteration  of,   99 
Lavage,  pelvic,  320 

in  renal  tuberculosis,  320 
Leucoplakia,  A-esical,  204,  240 

urethral,  94 
Lithiasis,   bladder,   364 

renal,  153 

ureteral,  154 
Lithotrity,  365 
Littre's  glands,  84,  95,  132,  146 

cystic,  97 
Luys'  urethroscope,  43 

cystoseope,  61,  224,  333 


M 


Meatotomy,  ureteral,  375 
Mucosa,  normal,  of  bladder,  149 
of  uretlira.  84 


N 


Neck  of  hladder,  176,  202,  310 

polypi  on,  270 
Neurasthenia,   cured  by  endoscopy,   125 


Papilloma,  vesical,  160,  163,  176,  202,  338 
Pelvis,  I'enal, 

capacity  of,  210.  313 
exploration  of,  313 
Perforation  of  bladder,  142,  176,  236 
Periureteritis,  301 
Periurethral  abscess,  98 
Phantoms,  vesical,  167 
Photography,  A-esical,  179 
Polypi,  iir  female  urethra,  112 

on  verumontanum,  66 

on  A'esical  neck,  270 
Posterior  fossette,  101 
Posterior  urethra,  examination  of,  76 
Postmontane  space,   101 
Pregnancy,  cystoscopy  in,  241,  248 
Prismatic  cystoscopy,  168 
Prostatic  folliculitis,  101 

fossette,  52,  85.  105 

hypertrophy,  cystoscopy  in,  141 
endourethral  treatment  of,  135 
urethroscopy  in,  109 

utricle,  52,  87,  109,  118 
Prostatitis,  chronic  106,  122 
Pyelitis,  treatment  by  lavage,  320 
Pyelography,    326 

Pyonephrosis,  153,  277,  281,  316,  358 
Pyuria,  235 


E 


Radium  in  Idadder  tumors,  355 
Renal  function,  285,  319 

infection  by  ureter  catheter,  293 

lithiasis,   153 

pelvis,  capacity  of,  210 
exploration  of,  313 

tuberculosis,  153,  281 


S 


Seminal  vesicles : 

casts  of,  123 

inflammation  of,  124 

injection  into,  129 

urethrovesicular  reflex,  124 
Snare,  in  treatment  of  bladder  tumors,  342 
Soft  infiltration,  88,  101,  132 

central  figure  in,  90 
Solutions  used  in  pelvic  lavage,  323 
Spasm,  urethral,  190 
Spermatocystitis,  100,  126 
Stricture : 

of  ureter,  307,  377 

urethroscopic  view  of,  122,  132 
Suprapubic  cystotomy,  329 
Syphilis  of  bladder,  188 


T 


Test,  indigo  carmine,  159 
Trabcculations   of  bladder,   214 
Trigone,  ligaments  of,  249 
Tul^ereulosis,  renal,  153,  281 

pelvic  lavage  in,  320 

ureterovesical,  153 
Tuberculous  cystitis,  203 

ulcerations  of  bladder,  258 

ureteral  orifice,  258 
Tumors  of  Ijladder,  160,  205,  329,  358 

cystoscopy  in,  205 

treatment  of,  329 
Tumors  of  bladder  neck,  336 

U 

Ulcerations  of  bladder,  258 
Ureter : 

calculi,  307 

catheters,  262 

catheterization,  210,  214,  254,  291 

accidents  of,  293 

a  demeure,  324 

and  vesical   deformities,   253 

dangers  of,  291 

difficulties  in,  291 

errors  in,  298 

in  children,   306 

indications  for,  307 

Kelly's  method,  267 
ejaculation,  158,  176,  210,  214 
exploration  of,  374 
kink,    301 
lithiasis,  154 
jneatoscopy,  150 
obliteration,  301,  307 
orifices,  150,  176,  202,  210,  251 

anomalies  of,  157 

aspects  of,  150 

atresia  of,  152 

dilated,  153 

edema  of,  344 

golf-hole,  152 

in  pregnancy,  214 

location  of,  162 

prolapse  of,  155 

tuberculosis  of,  258 
radiography  of,  326 
stricture  of,  307 
Urethral  glands,  cystic,  97 
leucoplakia,  94 
spasm,  190 
Urethritis,  chronic  posterior,  106 
Urethroscopes : 

extei-nal  illumination: 

advantages  of,  35 

Antal,  31 

Auspitz,  33 

Casper,  30 

Clar,  32 

Desormeaux,  27 

disadvantages  of,  35 

Fenwick,  32 

Griinfeid,  32 

Horteloup,  28 

Janet,  34  ,    .  •    .  ' 


384 


INDEX 


Urethroscopes — Cont  'd. 

Kollmann-Weihe,  34 

Lang,  29 

Leiter,  28 

Nyrops,  29 

Otis,  30 

Schutze,  29 
internal  illumination : 

Goldschmidt,  49 

Gordon,  38 

Kaufmann,  38 

Luys,  40,  43 

Nitze,  36 

Oberlaender,  36 

Kollmanu,  37 

Valentine,  37 

Wasserthal,  38 
for  posterior  urethra : 

Buerger,  50 

Goldschmidt,  47 

Le  Fiir.  47 

Wossidlo,  50 
Urethroscopy : 
adrenalin  in,  81 
aly])in  in,  77 
central  tigure  in,  82 
contraindications  to,  81 
history  of,  27 
in  chronic  urethritis,  65 
in  determining  cure  of  urethritis,  68 
in  hard   infiltration,   88 
in  soft  infiltration,  88 


Urethroscopy — Cont'd. 

in  prostatic  hypertrophy,  109,  135 

in     the  female,  110 

lacunEs  of  Moigagni  in,  84 

of  normal  urethra,  82 

of  pathologic  urethra,   88,  100 

posterior,  76,  100 

technic  of,  70,  77 

Oberlaender  and  Kollmann,  69 
Urethrovesicovaginal  fistula,  214,  236 
(Jrethrovesicular  reflex,  124      **■ 
Uterine  cancer,  cystoscopy  in,  207,  211 
Utricle,  prostatic,  52,  87,  109,  118 

V    "^ 

A^arix  of  bladder,  164,  207 
Vasopuncture,  126 
Vasotomy,  326 
Verumontanum,  87 

masturbator 's,  52,  109 

neurasthenia,  in  relation  to  the,  106 

normal.  87,  117 

polypi  on,  106 

vegetations  on,  106 

views  of,  52,  66,  104,  146 
Vesical  calculi,   364 

herpes,  228 

phantoms,  167 
Vesicular  casts,  123 
A^csiculoctomy,  126 
Vesiculotomy,  126 


INDEX  OF  AUTHORS 


A 

Albarran,  154,  2(32,  ?,0?, 
Albuquerque,  42 
Andre,  347 
Andrews,  26 
Antal,  31 
AscH,  42 
AuspiTZ,  33 
Ayres,  356 

B 

Bachrach,  347 

Baer,  180,  262 

Bar,  251 

Barbour,  251 

Barney,  347 

Bazy,  154 

Beer,  347 

Beleield.  246,  120,  126 

Berger,  180 

BiCKERSTETH,  62 

Binney,  347 
Blum,  347 
BoARi,  62,  364 
BoiiME,  347 
BozziNi,  25 
Braasch,  245,  328 
Brenner,  262 
Brown,  262 
BnucK,  55 
BucKY,  347 
B'UERGER,  50,  347 

Burns.  328 


C 


Cabot,  311 
Caspari,  341 
Casper,  31 
Cathelin,  305 
Clado,  42,  61 
colaneri,  217 
cottenot,  347 
Cruet,  207 
Crulse,  26,  54 

CULLEN, 60 


D 


Be  Gouvea,  125 

De  Ilyes,  326 

De  Keersmaecker,  42,  88,  99,  342 

Delbet,  61 

De  Mendoza,  42,  189 

Descjiaups,  294 

Desormeaux,  26 


Desvignes,  105 
d'Hallutn,  347 
DoMirER,  51 
Doyen,  347 


Elsner,  246 
ESCOMEL,  371 


F 


Fenwick,  32,  42,  158,  175    . 
Ferron,  62,  236,  291,  306 
Fisher,  25 
Fraisse,  42,  88,  100 
Frank,  305,  347 
Freudenberg,  262 
Fuller,  126 

FtJRSTENIIEIM,  26 

G 

Garceau,  58,  158,  302 
Gardner,  347 

Gautiiier,  62,  342,  364,  378 
Goldschmidt,  47 
Gordon,  38 
gorodichze,  265 
Grunfeld,  32,  56,  100,  269 
Gudin,  303 
guterbrock,  175 


H 


Hacken,  26 
Harpster,  136,  347 
Hartmann,  61.  297 
Heitz-Boyer,  28,  347 
Henriet,  364 
Henry,  42 
HoGGE,  59,  265 

HORTELOUP.   30 


Imbert,  262 
Israel,  295 


Jacoby--,  179 
Janet,  34,  61,  88,  100 
Jardon,  62,  374 
Jayle,  219 
Johnson,  81 
Joseph,  159 
JUDD,  347 


385 


386 


IXDF.X    OF    AUTHOliS 


K 


Kasenelsohn,  26 

Kaufmaxx,  38 

Keefe,  304 

Kelly,  57,  219,  246,  267,  30S,  319,  378 

KiDD,  327 

Klotz,  120 

KxoRE,  158 

Koch,  246 

Kollischer,  204 

KoLLMAXX,  34,  88,  99 

kouzxetzky,  299 

Keebs,  326 

Keotoszyxee.  327 

KUTTXER.  347 


Le  Dextu,  40 
Le  Fcr,  47,  364 
Legueu,  283,  297,  347 
Leiter,  36,  56 
Lepoutre,  347  ' 
Lewis,  59,  246,  378 

LuYS,  36,  40,  61,  120,  189,  217,  242,  246,  251, 
307,  320,  326,  371 


M 


Marculies,  294 
Mariox,  147,  332 
McCarthy,  347 
Millet,  246 

MlJEARD,  207 


N 


Nagelsciimidt,  347 

XiTZE,  36,  55,  168,  195,  207,  210,  223,  302,  331 

Xyeops,  31 

O 

Oberlaexder,  34,  36,  88,  99 
Oppexheimer,  354 
Otis,  31,  89 


Pasteau,  154 
Paul,  43 
Pawlick,  58,  269 
Pilciier,  347 
ProxTiK,  239 


Pozzi.  311 
Pulido-Martin,  371 


Eafin,  298 
EocKER,  175,  306 


Schlagixtaveit,  17' 
Schutze,  31 
Segalas,  26 
Siourta,  71 
StXCLAIR,  347 
Sx-ELL,  246 
Steix,  26 
Stephaxi,  242 
Sterx,  42 


Taverxier,  242 
Terrier,  230 
TixiER,  342 
Ti-FFIER.  242,  297 


U 


Uteau,  149 


Valentine,  37 
Verxeuil,  242 
Viertel,  207 
Violet,  207 
Voelcker,  159 
vox  Friscii,  42 


W 


Wasserthal,  38 

Watson,  347 

Webster,  61 

Weixricii,  331 

WiEiiE,  34 

Wolbarst,  100,  347,  378 

Wormser,  42 

WossiDLO,  42,  50,  88,  100 


ZWEIFEL,  251 
ZUCKERKAXDL,  42,  200,  207 


''^tffi^^NrVERS.TY  LIBRARIES 


0052843696 


DATE  DUE 

Demco.  Inc.  38-293 


